Basic Information
| Provider Information | |||||||||
| NPI: | 1588675698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZULLO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017898543 | ||||||||
| FaxNumber: | 4017828766 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017898543 | ||||||||
| FaxNumber: | 4017828766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 06480 | RI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | J11769 | 01 | MA | MABC | OTHER | 052518 | 01 | MA | TUFTS | OTHER | 35998 | 01 | MA | FALLON | OTHER | 0101102 | 01 | UHC | OTHER | 400988 | 01 | RI BLUE CHIP | OTHER | B10350101 | 01 | MA | CIGNA | OTHER | 000000028143 | 01 | MA | BMC HEALTHNET | OTHER | 3043355 | 05 | MA | MEDICAID | 710716 | 01 | MA | HPHC | OTHER |