1669430211 NPI number — MRS. KIMBERLY R BRISTOW OD

Table of content: MRS. KIMBERLY R BRISTOW OD (NPI 1669430211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669430211 NPI number — MRS. KIMBERLY R BRISTOW OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTOW
Provider First Name:
KIMBERLY
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669430211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 CHESAPEAKE BLVD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
ELKTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-392-4976
Provider Business Mailing Address Fax Number:
410-392-4958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CENTURIAN DR
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-993-0722
Provider Business Practice Location Address Fax Number:
302-993-0754
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  13-0001241 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: TA1463 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 116251900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000542402 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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