Healthcare Provider Details

I. General information

NPI: 1780888529
Provider Name (Legal Business Name): KETAN RAMANLAL BULSARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 09/29/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

UCONN MEDICAL GROUP 263 FARMINGTON AVENUE
FARMINGTON CT
06030-8063
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax:
Mailing address:
  • Phone: 860-679-8080
  • Fax: 860-679-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number045293
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number045293
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: