Provider Demographics
NPI:1225002132
Name:BRISTOL, CLIFFORD STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:STUART
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17808 NE CHARLIE JOHNS ST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1052
Mailing Address - Country:US
Mailing Address - Phone:850-674-4524
Mailing Address - Fax:850-674-2300
Practice Address - Street 1:17808 NE CHARLIE JOHNS ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1052
Practice Address - Country:US
Practice Address - Phone:850-674-4524
Practice Address - Fax:850-674-2300
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059767800Medicaid
FL059767800Medicaid
FLD58658Medicare UPIN