Provider Demographics
NPI:1629118302
Name:PRUSTY, SUSHRUTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHRUTA
Middle Name:
Last Name:PRUSTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 EDGEWATER RD
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-2661
Mailing Address - Country:US
Mailing Address - Phone:781-925-8642
Mailing Address - Fax:
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-789-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157558207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine