1821194259 NPI number — DANNY RUSSELL BRISTOL OD

Table of content: (NPI 1629142765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821194259 NPI number — DANNY RUSSELL BRISTOL OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTOL
Provider First Name:
DANNY
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1821194259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11500 BEE CAVES ROAD
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-263-3937
Provider Business Mailing Address Fax Number:
512-263-3940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11500 BEE CAVES ROAD
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-263-3937
Provider Business Practice Location Address Fax Number:
512-263-3940
Provider Enumeration Date:
09/15/2006

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:  5613TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 5613TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: 5613TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0088FE . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 172729901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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