Provider Demographics
NPI:1558789933
Name:BORNSTEIN, ETHAN REUVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:REUVAN
Last Name:BORNSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EITAN
Other - Middle Name:
Other - Last Name:BORNSTEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7001
Mailing Address - Fax:
Practice Address - Street 1:PO BOX PH
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-8000
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0058527207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1558789933Medicaid