Healthcare Provider Details

I. General information

NPI: 1760580476
Provider Name (Legal Business Name): JOHN SCOTT TIDBALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23415 THREE NOTCH RD SUITE 2054 WILDEWOOD CENTER
CALIFORNIA MD
20619-4017
US

IV. Provider business mailing address

23415 THREE NOTCH RD SUITE 2054
CALIFORNIA MD
20619-4017
US

V. Phone/Fax

Practice location:
  • Phone: 301-737-7833
  • Fax: 301-737-4865
Mailing address:
  • Phone: 301-737-7833
  • Fax: 301-737-4865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD52196
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: