Provider Demographics
NPI:1720381452
Name:JOHN R ISTAD PA
Entity Type:Organization
Organization Name:JOHN R ISTAD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ISTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-398-5400
Mailing Address - Street 1:1105 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5332
Mailing Address - Country:US
Mailing Address - Phone:772-398-5400
Mailing Address - Fax:772-398-6600
Practice Address - Street 1:1105 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5332
Practice Address - Country:US
Practice Address - Phone:772-398-5400
Practice Address - Fax:772-398-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6232261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU24555Medicare UPIN
FL22649Medicare PIN