Provider Demographics
NPI:1902836976
Name:ETIENNE, JACQUES EDOUARD (MD, FAAP)
Entity Type:Individual
Prefix:MR
First Name:JACQUES
Middle Name:EDOUARD
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MAIN ST. 1ST FL
Mailing Address - Street 2:OPTIMUM MEDICAL LLC
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-794-9000
Mailing Address - Fax:203-794-9005
Practice Address - Street 1:205 MAIN ST. 1ST FL
Practice Address - Street 2:OPTIMUM MEDICAL LLC
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-794-9000
Practice Address - Fax:203-794-9005
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042829208000000X
NY233345-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008023919Medicaid