Healthcare Provider Details

I. General information

NPI: 1700863412
Provider Name (Legal Business Name): TIMOTHY DEAN KISTLER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 W LYTLE ST
FOSTORIA OH
44830-3422
US

IV. Provider business mailing address

614 W LYTLE ST
FOSTORIA OH
44830-3422
US

V. Phone/Fax

Practice location:
  • Phone: 419-435-3554
  • Fax: 419-436-1994
Mailing address:
  • Phone: 419-435-3554
  • Fax: 419-436-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36-00-3099-K
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number36003099
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: