Provider Demographics
NPI:1700863412
Name:KISTLER, TIMOTHY DEAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DEAN
Last Name:KISTLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W LYTLE ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-3422
Mailing Address - Country:US
Mailing Address - Phone:419-435-3554
Mailing Address - Fax:419-436-1994
Practice Address - Street 1:614 W LYTLE ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-3422
Practice Address - Country:US
Practice Address - Phone:419-435-3554
Practice Address - Fax:419-436-1994
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3099-K213ES0131X
OH36003099332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH480026415OtherMEDICARE RR
OH2092239Medicaid
OHU63761Medicare UPIN
OH2092239Medicaid
OH480026415OtherMEDICARE RR