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General NPI Number Information
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NPI Number | 1295701241
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Entity Type | Individual
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Provider Name | WILLIAM LEWIS TIDMORE M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 149 HART ST SUITE #5
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City | WICHITA FALLS
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State | TX
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Zip | 76311-3477
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Country | US
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Telephone | 940-676-1886
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Fax |
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Provider Business Mailing Address
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Address Line | 4311 GRANTS GLN
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City | WICHITA FALLS
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State | TX
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Zip | 76309-1424
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Country | US
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Telephone | 940-696-1291
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | D6550
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License Number State | TX
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