Basic Information
| Provider Information | |||||||||
| NPI: | 1750362109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISTLER | ||||||||
| FirstName: | ERNEST | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9600 | ||||||||
| Address2: | DEPT 09-039 | ||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755059600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662148600 | ||||||||
| FaxNumber: | 8884114191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT MARY PL | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662148600 | ||||||||
| FaxNumber: | 8884114191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 014584 | LA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1344877 | 05 | LA | MEDICAID | 050016353 | 01 | LA | MEDICARE RAILROAD | OTHER |