Provider Demographics
NPI:1598322877
Name:TIHISTA, MIKEL
Entity type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:TIHISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-0148
Mailing Address - Country:US
Mailing Address - Phone:270-504-1910
Mailing Address - Fax:270-298-3824
Practice Address - Street 1:1215 OLD MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1619
Practice Address - Country:US
Practice Address - Phone:270-730-5344
Practice Address - Fax:270-298-9506
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59432207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery