Individual
DR. WALTER DAVID KISTLER JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
950 FRANCIS PL, S-113, SAINT LOUIS, MO 63105-2465
(314) 721-0411
(314) 721-5968
Mailing address
950 FRANCIS PL, S-113, SAINT LOUIS, MO 63105-2465
(314) 721-0411
(314) 721-5968
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
R3878
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000003759
PTAN
MO
01
—
178790
BLUE CROSS BLUE SHIELD
MO
01
—
186857
GHP
MO
05
—
200690907
—
MO
01
—
431059684
FED TAX ID
—
01
—
P00174135
RAILROAD MEDICARE
—
Enumeration date
07/07/2005
Last updated
05/11/2015
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