Healthcare Provider Details

I. General information

NPI: 1871098376
Provider Name (Legal Business Name): DEBORA ZAMORA-OLIVENCIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 W CENTER ST
MANCHESTER CT
06040-4735
US

IV. Provider business mailing address

388 W CENTER ST
MANCHESTER CT
06040-4735
US

V. Phone/Fax

Practice location:
  • Phone: 860-649-1120
  • Fax:
Mailing address:
  • Phone: 860-649-1120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14407-I
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number72163
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21006
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: