MEDICARE: JOHN R ISTAD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	CH6232	FL

General Provider Information

NPI Number	:	1720381452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN R ISTAD PA

Provider Business Mailing Address
First Line	:	1105 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5332
Country	:	US
Telephone Number	:	772-398-5400
Fax Number	:	772-398-6600

Provider Business Practice Location Address
First Line	:	1105 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5332
Country	:	US
Telephone Number	:	772-398-5400
Fax Number	:	772-398-6600

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN R ISTAD
Credential	:	DC
Telephone Number	:	772-398-5400

Provider Enumeration Date	:	12/20/2010
Last Update Date	:	03/11/2011

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