Basic Information
| Provider Information | |||||||||
| NPI: | 1942704317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETIENNE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RUBBEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 W RED BANK AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568532056 | ||||||||
| FaxNumber: | 8566865218 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 BARTON BLVD UNIT C14 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216395177 | ||||||||
| FaxNumber: | 3216394927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | ME145925 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.