Provider Demographics
NPI:1386626026
Name:KISTLER, J PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:PHILIP
Last Name:KISTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:VBK 802
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8459
Practice Address - Fax:617-726-5043
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38279207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM08997OtherBCBS MA
MA038279OtherTUFTS HEALTH PLAN
MA2066858Medicaid
MA038279OtherTUFTS HEALTH PLAN
MAM08997OtherBCBS MA