Basic Information
| Provider Information | |||||||||
| NPI: | 1740237460 | ||||||||
| 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: | 16300 SAND CANYON AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495524200 | ||||||||
| FaxNumber: | 9492622300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCHAFER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| 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 | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.