Provider Demographics
NPI:1629358742
Name:BISTA, SUKIRTI (MD)
Entity type:Individual
Prefix:
First Name:SUKIRTI
Middle Name:
Last Name:BISTA
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:2295 E 14TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-6804
Practice Address - Country:US
Practice Address - Phone:336-713-8860
Practice Address - Fax:336-713-8862
Is Sole Proprietor?:No
Enumeration Date:2011-08-20
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-00991208000000X
PAMD446053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC76947477OtherMEDICARE
SC385283Medicaid