Healthcare Provider Details

I. General information

NPI: 1043266760
Provider Name (Legal Business Name): BRISTOL PARK MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 BAKER ST
COSTA MESA CA
92626-4320
US

IV. Provider business mailing address

2742 DOW AVE
TUSTIN CA
92780-7242
US

V. Phone/Fax

Practice location:
  • Phone: 714-557-6300
  • Fax: 714-966-9567
Mailing address:
  • Phone: 714-665-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK D SCHAFER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 714-665-1661