Provider Demographics
NPI:1336132729
Name:LYSTASH, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LYSTASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2244
Mailing Address - Country:US
Mailing Address - Phone:540-309-8210
Mailing Address - Fax:
Practice Address - Street 1:29 PLANTATION PARK DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-9001
Practice Address - Country:US
Practice Address - Phone:843-706-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91175207RC0000X
VA0101038597207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336132729Medicaid
VAB08193Medicare UPIN
VA060000568Medicare PIN