Basic Information
| Provider Information | |||||||||
| NPI: | 1396714820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETTENSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146813146 | ||||||||
| FaxNumber: | 9146826403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 THEALL RD | ||||||||
| Address2: | |||||||||
| City: | RYE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105801404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488800 | ||||||||
| FaxNumber: | 9146826403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 174308-1 | NY | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 041999 | CT | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 01072893 | 05 | NY | MEDICAID | 21E601 | 01 | NY | EMPIRE BCBS | OTHER | 133757245 | 01 | NY | CIGNA | OTHER |