Provider Demographics
NPI:1962666511
Name:RULLO, KRISTIN STANLEY (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:STANLEY
Last Name:RULLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WORTHEN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4835
Mailing Address - Country:US
Mailing Address - Phone:781-862-1828
Mailing Address - Fax:781-863-9416
Practice Address - Street 1:21 WORTHEN ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421
Practice Address - Country:US
Practice Address - Phone:781-862-1828
Practice Address - Fax:781-863-9416
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4662152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0728489Medicaid
MA675901Medicare PIN
MA675902Medicare PIN