Healthcare Provider Details

I. General information

NPI: 1265413926
Provider Name (Legal Business Name): CHAITANYA MUDGAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST YAW 2100
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-5100
  • Fax:
Mailing address:
  • Phone: 617-726-4700
  • Fax: 617-724-8532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number153170
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: