Provider Demographics
NPI:1043274368
Name:IDICULLA, STANLEY (DPM)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:IDICULLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ELDEN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4874
Mailing Address - Country:US
Mailing Address - Phone:703-437-5353
Mailing Address - Fax:
Practice Address - Street 1:112 ELDEN ST
Practice Address - Street 2:SUITE D
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4874
Practice Address - Country:US
Practice Address - Phone:703-437-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAXXXX213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101437Medicare PIN
DC144284Y74Medicare PIN