Provider Demographics
NPI:1245221704
Name:TIDSWELL, JEFFREY REED (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:REED
Last Name:TIDSWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:719-633-0284
Practice Address - Street 1:1625 E PLATTE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5620
Practice Address - Country:US
Practice Address - Phone:719-632-3561
Practice Address - Fax:719-633-0284
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08011843Medicaid
COT60854Medicare UPIN
CO08011843Medicaid