Provider Demographics
NPI:1255740619
Name:KIVA SHTULL MD
Entity type:Organization
Organization Name:KIVA SHTULL MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-431-0927
Mailing Address - Street 1:4450 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-1126
Mailing Address - Country:US
Mailing Address - Phone:216-431-0927
Mailing Address - Fax:
Practice Address - Street 1:4450 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1126
Practice Address - Country:US
Practice Address - Phone:216-431-0927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051031261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health