Provider Demographics
NPI:1164833612
Name:KISTLER, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:KISTLER
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 1:1941 LIMESTONE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5413
Mailing Address - Country:US
Mailing Address - Phone:302-655-9494
Mailing Address - Fax:302-691-1478
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-17
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT206253207X00000X
DEC1-0013633207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery