Provider Demographics
NPI:1477819951
Name:NISTICO, JUSTIN ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:NISTICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:602 IVY ST FL 1
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1646
Practice Address - Country:US
Practice Address - Phone:607-737-4577
Practice Address - Fax:607-367-5010
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY277019207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04209610Medicaid
PA103467400Medicaid