Provider Demographics
NPI:1942250162
Name:CHLYSTA, WALTER J (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:CHLYSTA
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 1:1900 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1404
Mailing Address - Country:US
Mailing Address - Phone:330-926-3443
Mailing Address - Fax:330-255-5092
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-926-3443
Practice Address - Fax:330-255-5092
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070064208600000X
OH35.070064208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2101086Medicaid
OH020049032OtherRR MEDICARE
OH341971582OtherTRICARE NORTH
OH2101086Medicaid
OH0870422Medicare PIN
OHG91688Medicare UPIN