Provider Demographics
NPI:1467884478
Name:IDICULLA, JASON JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:JOSEPH
Last Name:IDICULLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14897 SOUTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-5016
Mailing Address - Country:US
Mailing Address - Phone:281-265-1001
Mailing Address - Fax:281-265-1286
Practice Address - Street 1:14897 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-5016
Practice Address - Country:US
Practice Address - Phone:281-265-1001
Practice Address - Fax:281-265-1286
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8235T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist