Basic Information
| Provider Information | |||||||||
| NPI: | 1689621260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRISTOL PARK MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2742 DOW AVE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927807242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146651600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11420 WARNER AVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927082529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145491300 | ||||||||
| FaxNumber: | 9497984406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCHAFER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7146651661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0069197 | 05 | CA | MEDICAID |