Healthcare Provider Details

I. General information

NPI: 1598322877
Provider Name (Legal Business Name): MIKEL TIHISTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 06/07/2025
Certification Date: 06/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

PO BOX 148
HARTFORD KY
42347-0148
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8372
  • Fax:
Mailing address:
  • Phone: 270-504-1910
  • Fax: 270-298-3824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number59432
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: