Provider Demographics
NPI:1962604777
Name:RULLAN, MAYRA (OD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:RULLAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MAYRA
Other - Middle Name:
Other - Last Name:RULLAN RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:148 CALLE MIRAMONTE
Mailing Address - Street 2:GRAN VISTA I
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778-5007
Mailing Address - Country:US
Mailing Address - Phone:787-765-1915
Mailing Address - Fax:
Practice Address - Street 1:118 CALLE ELEONOR ROOSEVELT
Practice Address - Street 2:IAU SCHOOL OF OPTOMETRY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3105
Practice Address - Country:US
Practice Address - Phone:787-765-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRU79100Medicare UPIN