Provider Demographics
NPI:1952331837
Name:GIST, DARNELLA D (MD)
Entity Type:Individual
Prefix:
First Name:DARNELLA
Middle Name:D
Last Name:GIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 OLD GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9489
Mailing Address - Country:US
Mailing Address - Phone:262-687-7606
Mailing Address - Fax:
Practice Address - Street 1:1350 S SUNNY SLOPE RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7060
Practice Address - Country:US
Practice Address - Phone:262-798-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H45688Medicare UPIN