Provider Demographics
NPI:1730171166
Name:KISTLER, KENT H (MD)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:H
Last Name:KISTLER
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 1:1130 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4620
Mailing Address - Country:US
Mailing Address - Phone:864-232-9644
Mailing Address - Fax:864-232-7825
Practice Address - Street 1:1130 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4620
Practice Address - Country:US
Practice Address - Phone:864-232-9644
Practice Address - Fax:864-232-7825
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC120229Medicaid
B91672Medicare UPIN
SCB91672Medicare ID - Type Unspecified