Provider Demographics
NPI:1093883761
Name:OCHOTORENA, CONCEPCION CABANTAC (MD)
Entity type:Individual
Prefix:
First Name:CONCEPCION
Middle Name:CABANTAC
Last Name:OCHOTORENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONCEPCION
Other - Middle Name:
Other - Last Name:CABANTAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 BANCROFT LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2463
Mailing Address - Country:US
Mailing Address - Phone:231-880-3894
Mailing Address - Fax:860-291-9506
Practice Address - Street 1:335 BROAD ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4036
Practice Address - Country:US
Practice Address - Phone:860-643-3200
Practice Address - Fax:860-643-3201
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035190208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A62719Medicare UPIN
CT010000735Medicare ID - Type UnspecifiedFIRST COAST CEDARS
CT790000002Medicare ID - Type UnspecifiedFIRST COAST CONN VALLEY