Provider Demographics
NPI:1871554543
Name:ETZKORN, EMILY T (MD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:T
Last Name:ETZKORN
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 1:5010 STATE HIGHWAY 30
Mailing Address - Street 2:SUITE G-02
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7532
Mailing Address - Country:US
Mailing Address - Phone:518-842-0017
Mailing Address - Fax:518-842-7545
Practice Address - Street 1:5010 STATE HIGHWAY 30
Practice Address - Street 2:SUITE G-02
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7532
Practice Address - Country:US
Practice Address - Phone:518-842-0017
Practice Address - Fax:518-842-7545
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2024171207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02047565Medicaid
NYAA1401Medicare ID - Type Unspecified
NY02047565Medicaid