Provider Demographics
NPI:1679558118
Name:ETRA, RICHARD G (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:ETRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:175 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-622-6000
Mailing Address - Fax:
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5100
Practice Address - Country:US
Practice Address - Phone:516-487-6200
Practice Address - Fax:516-487-6329
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128003207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY28A921Medicare ID - Type UnspecifiedM.D.
NYB12154Medicare UPIN