Provider Demographics
NPI:1124160353
Name:ISTAD, JOHN R (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:ISTAD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5332
Mailing Address - Country:US
Mailing Address - Phone:772-398-5400
Mailing Address - Fax:772-398-6600
Practice Address - Street 1:1105 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5332
Practice Address - Country:US
Practice Address - Phone:772-398-5400
Practice Address - Fax:772-398-6600
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU24555Medicare UPIN
FL22649Medicare PIN