1629263694 NPI number — DR. SANDEE JEWEL BRISTOW MD

Table of content: DR. SANDEE JEWEL BRISTOW MD (NPI 1629263694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629263694 NPI number — DR. SANDEE JEWEL BRISTOW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTOW
Provider First Name:
SANDEE
Provider Middle Name:
JEWEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629263694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 223190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33022-3190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-974-5533
Provider Business Mailing Address Fax Number:
305-974-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3661 SOUTH MIAMI AVE
Provider Second Line Business Practice Location Address:
SUITE 1008
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-974-5533
Provider Business Practice Location Address Fax Number:
305-974-5553
Provider Enumeration Date:
09/12/2007

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: 2081P2900X , with the licence number:  MD60152790 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: 104374 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD60152790 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1629263694 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0280818 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: ME104374 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 017204600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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