Provider Demographics
NPI:1629060389
Name:SCULLY, CYRIL MALVIN JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:CYRIL
Middle Name:MALVIN
Last Name:SCULLY
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3510 SEVERN AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-3444
Mailing Address - Country:US
Mailing Address - Phone:504-455-1777
Mailing Address - Fax:504-455-5361
Practice Address - Street 1:3510 SEVERN AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3444
Practice Address - Country:US
Practice Address - Phone:504-455-1777
Practice Address - Fax:504-455-5361
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD006R213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1397679Medicaid
LAT19689Medicare UPIN
LA1397679Medicaid