Provider Demographics
NPI:1720215346
Name:OPTIMUM MEDICAL LLC
Entity Type:Organization
Organization Name:OPTIMUM MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-775-7949
Mailing Address - Street 1:205 MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6627
Mailing Address - Country:US
Mailing Address - Phone:203-794-9000
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6627
Practice Address - Country:US
Practice Address - Phone:203-794-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042829208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty