Provider Demographics
NPI:1740297829
Name:MANTEL, AUTUMN M (OD)
Entity type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:M
Last Name:MANTEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:14465 POTOMAC MILLS RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6807
Practice Address - Country:US
Practice Address - Phone:703-494-6184
Practice Address - Fax:703-499-9744
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003988152W00000X
VA0618003387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1048492Medicaid
WA368024OtherWA LABOR & INDUSTRIES