Provider Demographics
NPI:1891806642
Name:IDICULLA, GEORGE A (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:IDICULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 FLORIDA AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2160
Mailing Address - Country:US
Mailing Address - Phone:321-638-0888
Mailing Address - Fax:321-638-0830
Practice Address - Street 1:1029 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2160
Practice Address - Country:US
Practice Address - Phone:321-638-0888
Practice Address - Fax:321-638-0830
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376630600Medicaid
FL376630600Medicaid
FLF94395Medicare UPIN