Provider Demographics
NPI:1811950090
Name:ILCUS, LIDIA STANA (MD)
Entity type:Individual
Prefix:DR
First Name:LIDIA
Middle Name:STANA
Last Name:ILCUS
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 1:71 MDG
Mailing Address - Street 2:527 GOTT ROAD
Mailing Address - City:VANCE AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73705
Mailing Address - Country:US
Mailing Address - Phone:580-213-7494
Mailing Address - Fax:
Practice Address - Street 1:71 MDG
Practice Address - Street 2:527 GOTT ROAD
Practice Address - City:VANCE AFB
Practice Address - State:OK
Practice Address - Zip Code:73705
Practice Address - Country:US
Practice Address - Phone:580-213-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 75062207R00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine