1922005834 NPI number — DR. WALTER DAVID KISTLER JR. M.D.

Table of content: ANTONIO MESA D.O. (NPI 1093717167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922005834 NPI number — DR. WALTER DAVID KISTLER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KISTLER
Provider First Name:
WALTER
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KISTLER
Provider Other First Name:
W
Provider Other Middle Name:
DAVID
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922005834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 FRANCIS PL
Provider Second Line Business Mailing Address:
S-113
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63105-2465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-721-0411
Provider Business Mailing Address Fax Number:
314-721-5968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 FRANCIS PL
Provider Second Line Business Practice Location Address:
S-113
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63105-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-721-0411
Provider Business Practice Location Address Fax Number:
314-721-5968
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  R3878 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431059684 . This is a "FED TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 186857 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 200690907 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 178790 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00174135 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000003759 . This is a "PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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