Provider Demographics
NPI:1891086583
Name:JEAN PAUL ETIENNE, OD, PC
Entity type:Organization
Organization Name:JEAN PAUL ETIENNE, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-345-1850
Mailing Address - Street 1:729 N KEYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-2800
Mailing Address - Country:US
Mailing Address - Phone:812-345-1850
Mailing Address - Fax:866-670-7077
Practice Address - Street 1:3024 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5425
Practice Address - Country:US
Practice Address - Phone:812-330-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003348B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty