Healthcare Provider Details

I. General information

NPI: 1902836976
Provider Name (Legal Business Name): JACQUES EDOUARD ETIENNE M.D., F.A.A.P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MAIN ST. 1ST FL OPTIMUM MEDICAL LLC
DANBURY CT
06810
US

IV. Provider business mailing address

205 MAIN ST. 1ST FL OPTIMUM MEDICAL LLC
DANBURY CT
06810
US

V. Phone/Fax

Practice location:
  • Phone: 203-794-9000
  • Fax: 203-794-9005
Mailing address:
  • Phone: 203-794-9000
  • Fax: 203-794-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042829
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number233345-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: