Provider Demographics
NPI:1447221866
Name:ETIENNE, ALEX (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:ETIENNE
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 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2363
Mailing Address - Fax:401-456-6744
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2363
Practice Address - Fax:401-456-6744
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11719207R00000X, 207RA0401X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7058051Medicaid
RI412896OtherBLUE CHIP OF RI
RI29918OtherBLUE CROSS OF RI
RI007058051Medicare ID - Type Unspecified
RII44741Medicare UPIN