=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457081135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIRAN S. LULLA MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 WASHINGTON ST
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-434-8639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 WELLESLEY ST
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02493-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-237-5687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHILD AND ADOLESCENT PSYCHIATRIST
-----------------------------------------------------
Name | DR. KIRAN LULLA
-----------------------------------------------------
Credential | MD, MBA
-----------------------------------------------------
Telephone | 781-434-8639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------