Provider Demographics
NPI:1972036762
Name:SHTULL-LEBER, EYTAN
Entity Type:Individual
Prefix:
First Name:EYTAN
Middle Name:
Last Name:SHTULL-LEBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TANI
Other - Middle Name:
Other - Last Name:SHTULL-LEBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2601 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:480-500-2540
Practice Address - Fax:623-201-7954
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ59441207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program