Provider Demographics
NPI:1154383909
Name:KISTLER, LANE A (MD)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:A
Last Name:KISTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8750
Practice Address - Fax:414-328-8751
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18544207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00725802OtherRR MEDICARE
WI31039300Medicaid
WI31039300Medicaid
WIP00725802OtherRR MEDICARE
B54158Medicare UPIN