Provider Demographics
NPI:1053306803
Name:TIDIK, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:TIDIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CASA ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-5803
Mailing Address - Country:US
Mailing Address - Phone:805-544-8993
Mailing Address - Fax:805-544-0120
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-544-8993
Practice Address - Fax:805-544-0120
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57086174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG57086OtherMEDICAL LICENSE
CA00G570860Medicaid
CAWG57086CMedicare PIN
CA330002783Medicare PIN
CA00G570860Medicaid