Healthcare Provider Details

I. General information

NPI: 1073695292
Provider Name (Legal Business Name): WILLIAM C TIDMORE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2418 N OAK ST
VALDOSTA GA
31602-2576
US

IV. Provider business mailing address

2418 N OAK ST
VALDOSTA GA
31602-2576
US

V. Phone/Fax

Practice location:
  • Phone: 229-219-0247
  • Fax: 229-219-0837
Mailing address:
  • Phone: 229-219-0247
  • Fax: 229-219-0837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number041978
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: