Provider Demographics
NPI:1336525278
Name:REAGAN E. A. BRISTOL, D.O.
Entity Type:Organization
Organization Name:REAGAN E. A. BRISTOL, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRISTOL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-627-9840
Mailing Address - Street 1:3006 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5381
Mailing Address - Country:US
Mailing Address - Phone:419-627-9840
Mailing Address - Fax:
Practice Address - Street 1:3006 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5381
Practice Address - Country:US
Practice Address - Phone:419-627-9840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256628Medicaid
BR4040091OtherMEDICARE PROVIDER
OHG42369Medicare UPIN