Provider Demographics
NPI:1073695292
Name:TIDMORE, WILLIAM C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:C
Last Name:TIDMORE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2418 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2576
Mailing Address - Country:US
Mailing Address - Phone:229-219-0247
Mailing Address - Fax:229-219-0837
Practice Address - Street 1:2418 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2576
Practice Address - Country:US
Practice Address - Phone:229-219-0247
Practice Address - Fax:229-219-0837
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041978207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00701027CMedicaid
GA00701027GMedicaid
GA66BBBDH02Medicare ID - Type UnspecifiedTIFTON M/CARE #
GAF75736Medicare UPIN
GA00701027CMedicaid