Provider Demographics
NPI:1922091198
Name:KRISTOL, BRUCE IVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:IVAN
Last Name:KRISTOL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7243 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-3425
Mailing Address - Country:US
Mailing Address - Phone:904-739-5808
Mailing Address - Fax:904-739-2528
Practice Address - Street 1:2427 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2001
Practice Address - Country:US
Practice Address - Phone:904-738-5808
Practice Address - Fax:904-739-2528
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75534Medicare ID - Type Unspecified