Provider Demographics
NPI:1386691004
Name:BRISTOL PARK MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:BRISTOL PARK MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-665-1661
Mailing Address - Street 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:250 E YALE LOOP
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4697
Practice Address - Country:US
Practice Address - Phone:949-551-1090
Practice Address - Fax:949-262-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006919BMedicaid
CA1046350007Medicare NSC
CAGR006919BMedicaid