Healthcare Provider Details

I. General information

NPI: 1932722006
Provider Name (Legal Business Name): BRYAN MICHAEL MISTRETTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST STE D327
SPRINGFIELD IL
62702-3757
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8444
  • Fax: 217-545-7762
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036174964
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125076122
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: