| National Provider Identifier [NPI]: | 1164645610 |
| Last Name Of The Provider | MANGUIKIAN |
| First Name Of The Provider | DERTAD |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9936 MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | FAIRFAX |
| Zip Code Of The Provider | 220313901 |
| State Code Of The Provider | VA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Ophthalmology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 41 |
| Number Of Services | 3446 |
| Number Of Medicare Beneficiaries | 1279 |
| Total Submitted Charge Amount | 1242162 |
| Total Medicare Allowed Amount | 506450.73 |
| Total Medicare Payment Amount | 369147.35 |
| Total Medicare Standardized Payment Amount | 322907.21 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 41 |
| Number Of Medical Services | 3446 |
| Number Of Medicare Beneficiaries With Medical Services | 1279 |
| Total Medical Submitted Charge Amount | 1242162 |
| Total Medical Medicare Allowed Amount | 506450.73 |
| Total Medical Medicare Payment Amount | 369147.35 |
| Total Medical Medicare Standardized Payment Amount | 322907.21 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | 12 |
| Number Of Beneficiaries Age 65 to 74 | 467 |
| Number Of Beneficiaries Age 75 to 84 | 543 |
| Number Of Beneficiaries Age Greater 84 | 257 |
| Number Of Female Beneficiaries | 796 |
| Number Of Male Beneficiaries | 483 |
| Number Of Non Hispanic White Beneficiaries | 1117 |
| Number Of Black or African American Beneficiaries | 29 |
| Number Of AsianPacific Islander Beneficiaries | 71 |
| Number Of Hispanic Beneficiaries | 32 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 30 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1212 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 67 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 8 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 1 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.8811 |