Provider Demographics
NPI:1699983585
Name:ETIENNE, VIVIANE MARIE ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIANE
Middle Name:MARIE ANNE
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WILLOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1327
Mailing Address - Country:US
Mailing Address - Phone:516-665-8139
Mailing Address - Fax:
Practice Address - Street 1:4011 WARREN ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1734
Practice Address - Country:US
Practice Address - Phone:718-651-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01467289Medicaid
NY01467289Medicaid
F19268Medicare UPIN