Provider Demographics
NPI:1073153896
Name:TIDWELL, JOSH
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 N AVONDALE PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-3867
Mailing Address - Country:US
Mailing Address - Phone:317-541-8748
Mailing Address - Fax:
Practice Address - Street 1:2171 N AVONDALE PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-3867
Practice Address - Country:US
Practice Address - Phone:317-541-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant