Provider Demographics
NPI:1922216191
Name:BORTAN, ELENA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:
Last Name:BORTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PERKINS FARM DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:201-724-4434
Mailing Address - Fax:
Practice Address - Street 1:100 PERKINS FARM DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-870-6385
Practice Address - Fax:860-245-0000
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235541174400000X
CT048689174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA224972OtherLIMITED LICENSE