Provider Demographics
NPI:1952383937
Name:ETIENNE, JEAN-PAUL (OD)
Entity Type:Individual
Prefix:
First Name:JEAN-PAUL
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 S MCINTIRE DR STE 120
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4209
Practice Address - Country:US
Practice Address - Phone:812-332-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003348A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200528930AMedicaid
INV05647Medicare UPIN
IN549330CMedicare ID - Type Unspecified