Provider Demographics
NPI:1932163375
Name:INOCALLA, MARILOU V (MD)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:V
Last Name:INOCALLA
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 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1046
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-3061
Practice Address - Street 1:770 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1046
Practice Address - Country:US
Practice Address - Phone:276-223-3200
Practice Address - Fax:276-223-0617
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010481062084P0804X
VA0101481062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945298Medicaid
VA166785OtherVALUEOPTIONS
280114OtherANTHEM
VA280116OtherANTHEM
247755000OtherMAGELLAN
260023506OtherMEDICARE RAILROAD
VA280113OtherANTHEM
VA139018OtherANTHEM
260023506OtherMEDICARE RAILROAD
260002139Medicare PIN