Basic Information
| Provider Information | |||||||||
| NPI: | 1700314630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGIARACINA | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | |||||||||
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| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TAM | ||||||||
| OtherFirstName: | EMILY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 W 80TH PL | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197382180 | ||||||||
| FaxNumber: | 2197382847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2017 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18004152A | IN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.