Healthcare Provider Details

I. General information

NPI: 1396434403
Provider Name (Legal Business Name): SUSHRUT MADHUKAR INGAWALE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

2800 MAIN STREET DEPT OF MEDICINE
BRIDGEPORT CT
06606
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 475-210-5425
  • Fax: 475-210-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1027641
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: