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General NPI Number Information
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NPI Number | 1417154774
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Entity Type | Individual
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Provider Name | NATHAN ROBERT ETTEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 03/16/2010
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Provider Practice Location Address
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Address Line | 9000 SW 152ND ST SUITE 206
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City | PALMETTO BAY
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State | FL
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Zip | 33157-1981
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Country | US
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Telephone | 786-242-7755
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Fax | 786-242-0070
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Provider Business Mailing Address
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Address Line | 9000 SW 152ND ST SUITE 206
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City | PALMETTO BAY
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State | FL
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Zip | 33157-1981
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Country | US
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Telephone | 786-242-7755
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Fax | 786-242-0070
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC-3337
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License Number State | FL
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