Provider Demographics
NPI:1952365264
Name:KULLA, LAWRENCE M
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:M
Last Name:KULLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MASON RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1506
Mailing Address - Country:US
Mailing Address - Phone:617-244-2007
Mailing Address - Fax:
Practice Address - Street 1:851 MAIN ST
Practice Address - Street 2:SUITE 11
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1612
Practice Address - Country:US
Practice Address - Phone:781-331-4923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45807174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9734643Medicaid
MA9734643Medicaid
MAJ0223601Medicare PIN