Provider Demographics
NPI:1760671044
Name:KISTKA, ZACHARY AARON-FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:AARON-FRANCIS
Last Name:KISTKA
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 1:6301 UNIVERSITY COMMONS STE 210
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1590
Mailing Address - Country:US
Mailing Address - Phone:574-234-4016
Mailing Address - Fax:574-239-4607
Practice Address - Street 1:6301 UNIVERSITY COMMONS STE 210
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1590
Practice Address - Country:US
Practice Address - Phone:574-234-4016
Practice Address - Fax:574-239-4607
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077098A207RE0101X
TN47710207RE0101X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201369110Medicaid
IN163500005OtherMEDICARE PTAN