=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043627292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS TIDWELL DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2014
-----------------------------------------------------
Last Update Date | 05/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 SAINT FRANCIS DR STE 510
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50702-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-272-5000
-----------------------------------------------------
Fax | 319-272-5236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 754 S MAIN ST
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84770-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-628-2671
-----------------------------------------------------
Fax | 435-674-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 5593046-0501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 074484
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------