Provider Demographics
NPI:1326072810
Name:PETROSINO, RAFFAELE A (OD)
Entity Type:Individual
Prefix:DR
First Name:RAFFAELE
Middle Name:A
Last Name:PETROSINO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-2309
Mailing Address - Country:US
Mailing Address - Phone:781-245-1871
Mailing Address - Fax:781-245-7963
Practice Address - Street 1:22 YALE AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-2309
Practice Address - Country:US
Practice Address - Phone:781-245-1871
Practice Address - Fax:781-245-7963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MA3862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA152-122OtherHARVARD PILGRIM
MA755438OtherTUFTS
MA32916OtherFALLON
MAW16034OtherBC BS OF MA
MA0369349Medicaid
MA0369349Medicaid
MA755438OtherTUFTS
MAU56762Medicare UPIN