Healthcare Provider Details

I. General information

NPI: 1427016039
Provider Name (Legal Business Name): ROBERT E. BRISTOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DRIVE SOUTH
ORANGE CA
92868
US

IV. Provider business mailing address

PO BOX 513980
LOS ANGELES CA
90051-3980
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6700
  • Fax:
Mailing address:
  • Phone: 714-456-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD53552
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberG81369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: