Provider Demographics
NPI:1528079837
Name:MACIULLA, LORI JEAN (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:MACIULLA
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 1:6707 OLD DOMINION DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4504
Mailing Address - Country:US
Mailing Address - Phone:703-288-4330
Mailing Address - Fax:703-556-0347
Practice Address - Street 1:6707 OLD DOMINION DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4504
Practice Address - Country:US
Practice Address - Phone:703-288-4330
Practice Address - Fax:703-556-0347
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01001043172207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
516252OtherMAMSI
4315636OtherAETNA
VA259156OtherANTHEM BCBS
DC32070001OtherCAREFIRST BCBS
E23114Medicare UPIN
VA259156OtherANTHEM BCBS