Provider Demographics
NPI:1275972325
Name:TIDWELL, TIMOTHY N (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:N
Last Name:TIDWELL
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 1:5920 WEST MALL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4232
Mailing Address - Country:US
Mailing Address - Phone:805-466-0676
Mailing Address - Fax:805-466-4862
Practice Address - Street 1:5920 WEST MALL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:805-466-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine