Healthcare Provider Details

I. General information

NPI: 1033161740
Provider Name (Legal Business Name): JONATHAN KISTLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NEEDHAM ST
MODESTO CA
95354-0730
US

IV. Provider business mailing address

1001 NEEDHAM ST
MODESTO CA
95354-0730
US

V. Phone/Fax

Practice location:
  • Phone: 209-569-0373
  • Fax: 209-529-8519
Mailing address:
  • Phone: 209-569-0373
  • Fax: 209-529-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA73938
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: