Provider Demographics
NPI:1932384179
Name:RAFFAELE A PETROSINO
Entity Type:Organization
Organization Name:RAFFAELE A PETROSINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFAELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETROSINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-245-1871
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1030520001Medicare NSC