Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0131X | Foot Surgery | XXXX | VA |
NPI | 1043274368 |
---|---|
Provider Name | Dr. Stanley Idiculla |
First Address | Herndon, VA 20170-4874 |
Second Address | Herndon, VA 20170-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2006 |
Last Update Date | 18/12/2013 |