Provider Demographics
NPI:1437150596
Name:BRISTOL, TYRONE GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:TYRONE
Middle Name:GARY
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 1:802 NEW HOLLAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2288
Mailing Address - Country:US
Mailing Address - Phone:717-560-3782
Mailing Address - Fax:717-560-3787
Practice Address - Street 1:802 NEW HOLLAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2288
Practice Address - Country:US
Practice Address - Phone:717-560-3782
Practice Address - Fax:717-560-3787
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053658L208000000X, 2084P0804X, 2084P0800X
NC2013-02294208000000X
NY198984208000000X
GA116582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2031Medicaid
NC1437150596Medicaid
NY01697965Medicaid
SCNC2031Medicaid
NYG07412Medicare PIN
NCNCG880AMedicare PIN