Basic Information
| Provider Information | |||||||||
| NPI: | 1255727228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLERTON | ||||||||
| FirstName: | RUSSELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 BOYLSTON ST APT 6G | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021997905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074461246 | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 REEDSDALE RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2015 | ||||||||
| LastUpdateDate: | 05/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 287107 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.