Provider Demographics
NPI:1821194259
Name:BRISTOL, DANNY RUSSELL (OD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:RUSSELL
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 BEE CAVES ROAD
Mailing Address - Street 2:#100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738
Mailing Address - Country:US
Mailing Address - Phone:512-263-3937
Mailing Address - Fax:512-263-3940
Practice Address - Street 1:11500 BEE CAVES ROAD
Practice Address - Street 2:#100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738
Practice Address - Country:US
Practice Address - Phone:512-263-3937
Practice Address - Fax:512-263-3940
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5613TG152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0088FEOtherBCBS
TX172729901Medicaid
TX0088FEOtherBCBS
TX611407Medicare PIN