Healthcare Provider Details

I. General information

NPI: 1114920600
Provider Name (Legal Business Name): JAMES TIDWELL MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9480 EL TEJADO RD
LA MESA CA
91941-4462
US

IV. Provider business mailing address

9480 EL TEJADO RD
LA MESA CA
91941-4462
US

V. Phone/Fax

Practice location:
  • Phone: 619-696-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG047644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: