Healthcare Provider Details

I. General information

NPI: 1568651388
Provider Name (Legal Business Name): NATALIE YAZDANI TIDWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 07/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 E MACK BAYOU DR
SANTA ROSA BEACH FL
32459-7102
US

IV. Provider business mailing address

1870 EDGE AVE
NICEVILLE FL
32578-2970
US

V. Phone/Fax

Practice location:
  • Phone: 863-263-7172
  • Fax:
Mailing address:
  • Phone: 863-263-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number062443
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number048717
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME105686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: