Provider Demographics
NPI:1225068638
Name:ETTINGHAUSEN, STEPHEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:ETTINGHAUSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 PORTLAND AVE
Mailing Address - Street 2:SUITE 245
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3038
Mailing Address - Country:US
Mailing Address - Phone:585-922-4874
Mailing Address - Fax:
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-922-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138462208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery