Provider Demographics
NPI:1063484327
Name:MISTR, ERNEST N (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:N
Last Name:MISTR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 WATERCREST DR
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-6940
Mailing Address - Country:US
Mailing Address - Phone:864-592-9358
Mailing Address - Fax:
Practice Address - Street 1:1330 BOILING SPRINGS RD
Practice Address - Street 2:SUITE 1300
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4201
Practice Address - Country:US
Practice Address - Phone:864-560-6345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101018666OtherMEDICAL LICENSE NUMBER
SC17303OtherMEDICAL LICENSE NUMBER
SCT11458Medicaid
SCB06890Medicare UPIN
SCT11458Medicaid
SCB068903365Medicare PIN