Provider Demographics
NPI:1780314682
Name:IDUL, MARIAH
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:IDUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4084 CONCORDIA WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-1760
Mailing Address - Country:US
Mailing Address - Phone:757-636-5849
Mailing Address - Fax:
Practice Address - Street 1:501 DISCOVERY DR
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3832
Practice Address - Country:US
Practice Address - Phone:757-547-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist