Provider Demographics
NPI:1114954559
Name:IDICULLA, ANNE A (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:A
Last Name:IDICULLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:J
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:802 N RIVERSIDE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2502
Mailing Address - Country:US
Mailing Address - Phone:816-271-7673
Mailing Address - Fax:816-271-4924
Practice Address - Street 1:802 N RIVERSIDE RD
Practice Address - Street 2:SUITE 260
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-9794
Practice Address - Country:US
Practice Address - Phone:816-271-7673
Practice Address - Fax:816-271-4924
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010866208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation