MEDICARE: DR. JAMES TIDWELL MD, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	G047644	CA

General Provider Information

NPI Number	:	1114920600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES TIDWELL MD, MPH

Provider Business Mailing Address
First Line	:	9480 EL TEJADO RD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-4462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9480 EL TEJADO RD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-4462
Country	:	US
Telephone Number	:	619-696-9800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2007

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