Provider Demographics
NPI:1265506505
Name:FELLUCA, EVELYN SYLVIA (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:SYLVIA
Last Name:FELLUCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-796-0200
Mailing Address - Fax:703-796-1690
Practice Address - Street 1:1860 TOWN CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5898
Practice Address - Country:US
Practice Address - Phone:703-796-0200
Practice Address - Fax:703-796-1690
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045226207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E81711Medicare UPIN
666306Medicare ID - Type Unspecified