Provider Demographics
NPI:1497761605
Name:KYLSTRA, JAN A (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:A
Last Name:KYLSTRA
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 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-662-5520
Mailing Address - Fax:
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 210
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-662-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52891207W00000X
SCAL33102207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8950484Medicaid
NC0366180001Medicare NSC
NCA59172Medicare UPIN
NC0366180016Medicare NSC
NC2142553DMedicare PIN