Provider Demographics
NPI:1144464850
Name:KISTKA, HEATHER (MD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:KISTKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:KIEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:50615 FOX TRL
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9040
Mailing Address - Country:US
Mailing Address - Phone:615-400-8549
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2485
Practice Address - Country:US
Practice Address - Phone:574-294-8404
Practice Address - Fax:574-523-1642
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076916A207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201365900Medicaid
IN327270005OtherMEDICARE PTAN
IN236040221OtherMEDICARE PTAN
IN201365900Medicaid
IN000001024807OtherANTHEM