Provider Demographics
NPI:1346504941
Name:ORTA COBO, MANUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:ORTA COBO
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:PO BOX 994
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-0994
Mailing Address - Country:US
Mailing Address - Phone:860-375-5088
Mailing Address - Fax:860-590-2030
Practice Address - Street 1:55 NYE RD STE 105
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1281
Practice Address - Country:US
Practice Address - Phone:860-375-5088
Practice Address - Fax:860-590-2030
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253331208000000X
FLME119697208000000X
FL14868390200000X
CT56881208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010977100Medicaid