Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 004060 | CT |
NPI | 1902899800 |
---|---|
Provider Name | Paul David Tortland |
First Address | Glastonbury, CT 06033-4535 |
Second Address | Glastonbury, CT 06033-4535 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2005 |
Last Update Date | 12/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F36941 | (02) | CT |