Provider Demographics
NPI:1386650760
Name:ISTFAN, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:ISTFAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4610 KANAWHA AVE SW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1367
Mailing Address - Country:US
Mailing Address - Phone:304-720-8701
Mailing Address - Fax:304-720-8702
Practice Address - Street 1:4610 KANAWHA AVE SW
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-720-8701
Practice Address - Fax:304-720-8702
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV14366207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910000444Medicaid
WV3910000444Medicaid
9298621Medicare ID - Type Unspecified