Provider Demographics
NPI:1629263694
Name:BRISTOW, SANDEE JEWEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDEE
Middle Name:JEWEL
Last Name:BRISTOW
Suffix:
Gender:F
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:PO BOX 223190
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33022-3190
Mailing Address - Country:US
Mailing Address - Phone:305-974-5533
Mailing Address - Fax:305-974-5553
Practice Address - Street 1:21000 NE 28TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1421
Practice Address - Country:US
Practice Address - Phone:305-974-5533
Practice Address - Fax:305-974-5553
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601527902081P2900X
FL1043742081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME104374OtherMEDICAL LICENSE
WA0280818OtherL&I
WA1629263694Medicaid
WAMD60152790OtherMEDICAL LICENSE
FLME104374OtherMEDICAL LICENSE