Provider Demographics
NPI:1245479948
Name:J.T. BRISTOL, M.D., LLC
Entity type:Organization
Organization Name:J.T. BRISTOL, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JYOJI
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRISTOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-818-6668
Mailing Address - Street 1:680 S MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3181
Mailing Address - Country:US
Mailing Address - Phone:860-818-6668
Mailing Address - Fax:
Practice Address - Street 1:680 S MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3181
Practice Address - Country:US
Practice Address - Phone:860-818-6668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty