Provider Demographics
NPI:1467432625
Name:ETTINGER, ALAN B (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:B
Last Name:ETTINGER
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 1:6080 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2850
Mailing Address - Country:US
Mailing Address - Phone:631-364-9119
Mailing Address - Fax:
Practice Address - Street 1:6080 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2850
Practice Address - Country:US
Practice Address - Phone:631-364-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1690052084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01346749Medicaid
NYA62090Medicare UPIN
NY01346749Medicaid
NY31E131Medicare ID - Type Unspecified