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General NPI Number Information
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NPI Number | 1639199862
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Entity Type | Individual
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Provider Name | JUSTIN TIDWELL M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 604 INDIANA
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City | LUBBOCK
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State | TX
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Zip | 79415
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Country | US
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Telephone | 806-775-9700
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Fax |
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Provider Business Mailing Address
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Address Line | 3804 53RD ST
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City | LUBBOCK
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State | TX
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Zip | 79413-3824
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Country | US
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Telephone | 806-795-0914
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | L5926
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License Number State | TX
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