Provider Demographics
NPI:1902899800
Name:TORTLAND, PAUL DAVID (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:TORTLAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 SYCAMORE ST
Mailing Address - Street 2:#301
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4535
Mailing Address - Country:US
Mailing Address - Phone:860-430-2821
Mailing Address - Fax:
Practice Address - Street 1:59 SYCAMORE ST
Practice Address - Street 2:#301
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4535
Practice Address - Country:US
Practice Address - Phone:860-430-2821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004060204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1200000069Medicare PIN
CTF36941Medicare UPIN