Provider Demographics
NPI:1407847023
Name:BRISTOW, WALTER J III (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:BRISTOW
Suffix:III
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 1:2739 LAUREL ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2028
Mailing Address - Country:US
Mailing Address - Phone:803-799-4800
Mailing Address - Fax:803-252-0052
Practice Address - Street 1:2739 LAUREL ST
Practice Address - Street 2:1-A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2028
Practice Address - Country:US
Practice Address - Phone:803-799-4800
Practice Address - Fax:803-252-0052
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16268207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL3154Medicaid
SCC72932A890Medicare PIN
SC4000Medicare PIN
SCC72932Medicare UPIN