Provider Demographics
NPI:1649256603
Name:MANGAT, TARA (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:MANGAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 825
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20146-0825
Mailing Address - Country:US
Mailing Address - Phone:703-858-0076
Mailing Address - Fax:703-726-6394
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:310
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8452
Practice Address - Country:US
Practice Address - Phone:703-858-0076
Practice Address - Fax:703-726-6394
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012325952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146222OtherANTHEM BC
G83920Medicare UPIN
VA00V975A01Medicare ID - Type Unspecified