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General NPI Number Information
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NPI Number | 1891086583
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Entity Type | Organization
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Legal Business Name | JEAN PAUL ETIENNE, OD, PC
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Dates
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Enumeration Date | 04/28/2011
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 3024 E 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5425
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Country | US
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Telephone | 812-330-2900
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Fax |
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Provider Business Mailing Address
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Address Line | 729 N KEYSTONE CT
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City | BLOOMINGTON
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State | IN
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Zip | 47408-2800
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Country | US
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Telephone | 812-345-1850
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Fax | 866-670-7077
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEAN PAUL ETIENNE
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Credential | OD
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Telephone | 812-345-1850
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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 | 18003348B
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License Number State | IN
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