Basic Information
Provider Information | |||||||||
NPI: | 1548348113 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRISTOL PARK MEDICAL GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2742 DOW AVE | ||||||||
Address2: |   | ||||||||
City: | TUSTIN | ||||||||
State: | CA | ||||||||
PostalCode: | 927807242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146651600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2742 DOW AVE | ||||||||
Address2: |   | ||||||||
City: | TUSTIN | ||||||||
State: | CA | ||||||||
PostalCode: | 927807242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146651661 | ||||||||
FaxNumber: | 7146651669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 10/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHAFER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7146651661 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 302F00000X |   |   | Y |   | Managed Care Organizations | Exclusive Provider Organization |   |
ID Information
ID | Type | State | Issuer | Description | GR0069197 | 05 | CA |   | MEDICAID | GR006919J | 05 | CA |   | MEDICAID | GR006919A | 05 | CA |   | MEDICAID | GR006919H | 05 | CA |   | MEDICAID | GR0069190 | 05 | CA |   | MEDICAID | GR0069196 | 05 | CA |   | MEDICAID | GR0069198 | 05 | CA |   | MEDICAID | GR006919G | 05 | CA |   | MEDICAID | GR0069199 | 05 | CA |   | MEDICAID | GR006919B | 05 | CA |   | MEDICAID | GR0069194 | 05 | CA |   | MEDICAID |