Provider Demographics
NPI:1356482103
Name:LEE D. ETTINGER, M.D., P.A.
Entity Type:Organization
Organization Name:LEE D. ETTINGER, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENOIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-974-7120
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 MAR WALT DR # C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-863-3199
Practice Address - Fax:850-863-3196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35386207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067872400Medicaid
FL110007848OtherMEDICARE RAILROAD
FL110007848OtherMEDICARE RAILROAD
FLK1531Medicare ID - Type Unspecified