Provider Demographics
NPI:1669430211
Name:BRISTOW, KIMBERLY R (OD)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:R
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CHESAPEAKE BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921
Mailing Address - Country:US
Mailing Address - Phone:410-392-4976
Mailing Address - Fax:410-392-4958
Practice Address - Street 1:1 CENTURIAN DR
Practice Address - Street 2:SUITE 114
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2137
Practice Address - Country:US
Practice Address - Phone:302-993-0722
Practice Address - Fax:302-993-0754
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE13-0001241152W00000X
MDTA1463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD116251900Medicaid
DE0000542402Medicaid
DE001069Medicare ID - Type Unspecified
DE0000542402Medicaid
MD116251900Medicaid