Healthcare Provider Details

I. General information

NPI: 1043627292
Provider Name (Legal Business Name): TRAVIS TIDWELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SAINT FRANCIS DR STE 510
WATERLOO IA
50702-5620
US

IV. Provider business mailing address

754 S MAIN ST
ST GEORGE UT
84770-5504
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-5000
  • Fax: 319-272-5236
Mailing address:
  • Phone: 435-628-2671
  • Fax: 435-674-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5593046-0501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number074484
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: