Provider Demographics
NPI:1902984230
Name:OTALORA, CARMEN (DOCTOR OF CHIRO)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:
Last Name:OTALORA
Suffix:
Gender:F
Credentials:DOCTOR OF CHIRO
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:DEL-CARMEN
Other - Last Name:OTALORA LEVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1300 WEST COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-905-5055
Mailing Address - Fax:732-905-9438
Practice Address - Street 1:1300 WEST COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-905-5055
Practice Address - Fax:732-905-9438
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00346200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ452742Medicare ID - Type Unspecified
T45293Medicare UPIN