Healthcare Provider Details

I. General information

NPI: 1720008907
Provider Name (Legal Business Name): MILL ETIENNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROUTE 59 STE 101
SUFFERN NY
10901-4927
US

IV. Provider business mailing address

20 GRAND ST FL 3
WARWICK NY
10990-1035
US

V. Phone/Fax

Practice location:
  • Phone: 845-368-8808
  • Fax: 845-357-0709
Mailing address:
  • Phone: 845-987-3906
  • Fax: 845-987-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number229737
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number229737
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number229737
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number229737
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02783493
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: