| Doctor Name: | DR. STANLEY IDICULLA |
| NPI Number: | 1043274368 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DPM |
| License Number: | XXXX |
| Business Practice Address: | 112 Elden St Suite D Herndon, VA - 201704874 |
| Business Phone Number: | 7034375353 |
| Business Fax Number: | |
| Mailing Address: | 112 Elden St, Suite D HERNDON |
| State: | VA |
| Postal Code: | 201704874 |
| Phone Number: | 7034375353 |
| Fax Number: | |
| NPI Enumeration Date: | 04/13/2006 |
| NPI Last Update Date: | 12/18/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 213ES0131X |
| License Number: | XXXX |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
| Taxonomy Classification: | Podiatrist |
| Taxonomy Specialization: | Foot Surgery |
| Taxonomy Definition: | |