Provider Demographics
NPI:1457676249
Name:JACK B KISTLER MD INC
Entity Type:Organization
Organization Name:JACK B KISTLER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:BARTLETT
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-682-6263
Mailing Address - Street 1:6900 BROCKTON AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3801
Mailing Address - Country:US
Mailing Address - Phone:951-682-6263
Mailing Address - Fax:951-682-0114
Practice Address - Street 1:6900 BROCKTON AVE STE 11
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3801
Practice Address - Country:US
Practice Address - Phone:951-682-6263
Practice Address - Fax:951-682-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC26186261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33065Medicare UPIN
CA00C261860Medicare PIN