Provider Demographics
NPI:1962481804
Name:BRISTOWE, KEVIN D (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:BRISTOWE
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:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:302-645-3296
Practice Address - Fax:302-645-3862
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005371207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000882401Medicaid
DE000882401Medicaid
G75013Medicare UPIN
DE0000882401Medicaid
DE000882401Medicaid