Healthcare Provider Details

I. General information

NPI: 1184758526
Provider Name (Legal Business Name): PAT THOMAS TIDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 E HIGHWAY 20 STE 203
NICEVILLE FL
32578-7700
US

IV. Provider business mailing address

4400 E HIGHWAY 20 STE 203
NICEVILLE FL
32578-7700
US

V. Phone/Fax

Practice location:
  • Phone: 850-897-3678
  • Fax: 850-373-4544
Mailing address:
  • Phone: 850-897-3678
  • Fax: 850-373-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME30890
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: