Healthcare Provider Details

I. General information

NPI: 1013986603
Provider Name (Legal Business Name): JERRY NEIL TIDWELL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 HENSLEE DR
DICKSON TN
37055-1211
US

IV. Provider business mailing address

610 HENSLEE DR
DICKSON TN
37055-1211
US

V. Phone/Fax

Practice location:
  • Phone: 615-446-2020
  • Fax: 615-441-2020
Mailing address:
  • Phone: 615-446-2020
  • Fax: 615-441-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000000818
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: