Provider Demographics
NPI:1922005834
Name:KISTLER, WALTER DAVID JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:DAVID
Last Name:KISTLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:W
Other - Middle Name:DAVID
Other - Last Name:KISTLER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:S-113
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-721-0411
Mailing Address - Fax:314-721-5968
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:S-113
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-721-0411
Practice Address - Fax:314-721-5968
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3878207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
431059684OtherFED TAX ID
MO186857OtherGHP
MO200690907Medicaid
MO178790OtherBLUE CROSS BLUE SHIELD
P00174135OtherRAILROAD MEDICARE
MO000003759OtherPTAN
A10850Medicare UPIN