Basic Information
| Provider Information | |||||||||
| NPI: | 1922216191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORTAN | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 PERKINS FARM DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017244434 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 PERKINS FARM DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608706385 | ||||||||
| FaxNumber: | 8602450000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2007 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 235541 | MA | N | Other Service Providers | Specialist | 174400000X | 048689 | CT | N | Other Service Providers | Specialist | 2084N0400X | 048689 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 224972 | 01 | MA | LIMITED LICENSE | OTHER |