Healthcare Provider Details

I. General information

NPI: 1225002132
Provider Name (Legal Business Name): CLIFFORD STUART BRISTOL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17808 NE CHARLIE JOHNS ST
BLOUNTSTOWN FL
32424-1052
US

IV. Provider business mailing address

17808 NE CHARLIE JOHNS ST
BLOUNTSTOWN FL
32424-1052
US

V. Phone/Fax

Practice location:
  • Phone: 850-674-4524
  • Fax: 850-674-2300
Mailing address:
  • Phone: 850-674-4524
  • Fax: 850-674-2300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME30535
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: