MEDICARE: DOAN KISTNER RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	PT 14083	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023461266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOAN KISTNER RPT

Provider Business Mailing Address
First Line	:	3950 SW 53RD CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-8202
Country	:	US
Telephone Number	:	954-309-9974
Fax Number	:

Provider Business Practice Location Address
First Line	:	3950 SW 53RD CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-8202
Country	:	US
Telephone Number	:	954-309-9974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2016
Last Update Date	:	07/22/2016

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