Provider Demographics
NPI:1043366347
Name:KISTLER, TIMOTHY J (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:KISTLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 GRANITE ST
Mailing Address - Street 2:STE 3
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5350
Mailing Address - Country:US
Mailing Address - Phone:317-826-2273
Mailing Address - Fax:317-826-2673
Practice Address - Street 1:111 WILLARD ST STE 2A
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1274
Practice Address - Country:US
Practice Address - Phone:617-804-7464
Practice Address - Fax:617-471-1114
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001237111NS0005X
MA3594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00006924OtherRAILROAD MEDICARE
IN000000344943OtherBCBS
IN200077400AMedicaid
INAETNAOther4351909
IN6904776002OtherCIGNA
IN206410AMedicare ID - Type Unspecified