Healthcare Provider Details

I. General information

NPI: 1114273224
Provider Name (Legal Business Name): MICHAEL S TIDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N PENNSYLVANIA AVE SUITE 103
OKLAHOMA CITY OK
73112-8886
US

IV. Provider business mailing address

5005 N PENNSYLVANIA AVE SUITE 103
OKLAHOMA CITY OK
73112-8886
US

V. Phone/Fax

Practice location:
  • Phone: 405-753-4269
  • Fax:
Mailing address:
  • Phone: 405-753-4269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: