Provider Demographics
NPI:1801806658
Name:ETIENNE, JEAN RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:RICHARD
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2848 S SEACREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7935
Mailing Address - Country:US
Mailing Address - Phone:561-738-7611
Mailing Address - Fax:561-738-7622
Practice Address - Street 1:2848 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7935
Practice Address - Country:US
Practice Address - Phone:561-738-7611
Practice Address - Fax:561-738-7622
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94307207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB118YMedicare PIN