Basic Information
| Provider Information | |||||||||
| NPI: | 1629263694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRISTOW | ||||||||
| FirstName: | SANDEE | ||||||||
| MiddleName: | JEWEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 223190 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330223190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059745533 | ||||||||
| FaxNumber: | 3059745553 | ||||||||
| Practice Location | |||||||||
| Address1: | 21000 NE 28TH AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059745533 | ||||||||
| FaxNumber: | 3059745553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | MD60152790 | WA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | 104374 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME104374 | 01 | FL | MEDICAL LICENSE | OTHER | 0280818 | 01 | WA | L&I | OTHER | 1629263694 | 05 | WA | MEDICAID | MD60152790 | 01 | WA | MEDICAL LICENSE | OTHER |