Provider Demographics
NPI:1417154774
Name:ETTEN, NATHAN ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ROBERT
Last Name:ETTEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 SW 152ND ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1981
Mailing Address - Country:US
Mailing Address - Phone:786-242-7755
Mailing Address - Fax:786-242-0070
Practice Address - Street 1:9000 SW 152ND ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1981
Practice Address - Country:US
Practice Address - Phone:786-242-7755
Practice Address - Fax:786-242-0070
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-3337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist