Provider Demographics
NPI:1407951734
Name:ETHERTON, STEVEN W (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:W
Last Name:ETHERTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-749-6187
Mailing Address - Fax:812-749-4966
Practice Address - Street 1:1204 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:OAKLAND CITY
Practice Address - State:IN
Practice Address - Zip Code:47660-1001
Practice Address - Country:US
Practice Address - Phone:812-749-6187
Practice Address - Fax:812-749-4966
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003011A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200808030Medicaid
IN000000522101OtherBCBS PIN
INM400038611Medicare PIN
IN000000522101OtherBCBS PIN
IN282330FMedicare PIN
INP00305213Medicare ID - Type UnspecifiedRR MCARE #