Provider Demographics
NPI:1457974891
Name:BRISTOW, ROBERT DAVID
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PRIVATE ROAD 616
Mailing Address - Street 2:
Mailing Address - City:BECKVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75631-6806
Mailing Address - Country:US
Mailing Address - Phone:903-216-9876
Mailing Address - Fax:
Practice Address - Street 1:117 PRIVATE ROAD 616
Practice Address - Street 2:
Practice Address - City:BECKVILLE
Practice Address - State:TX
Practice Address - Zip Code:75631-6806
Practice Address - Country:US
Practice Address - Phone:903-216-9876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352285164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse