Healthcare Provider Details

I. General information

NPI: 1336132729
Provider Name (Legal Business Name): JOHN C. LYSTASH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 PLANTATION PARK DR
BLUFFTON SC
29910-9001
US

IV. Provider business mailing address

12 PRIMROSE LN
HILTON HEAD ISLAND SC
29926-2244
US

V. Phone/Fax

Practice location:
  • Phone: 843-706-7090
  • Fax:
Mailing address:
  • Phone: 540-309-8210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number91175
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101038597
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: