Provider Demographics
NPI:1346208725
Name:TIDWELL, RICHARD H (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 987
Mailing Address - Street 2:2485 N MAIN ST
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0987
Mailing Address - Country:US
Mailing Address - Phone:918-253-2550
Mailing Address - Fax:918-253-2122
Practice Address - Street 1:2485 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-0987
Practice Address - Country:US
Practice Address - Phone:918-253-2550
Practice Address - Fax:918-253-2122
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200134610AMedicaid
OK100102630FMedicaid
OK201190171OtherTRI CARE
OK201190171OtherTRI CARE
OK200134610AMedicaid
OKP00179118Medicare PIN
OK400522398Medicare PIN
OK244434503Medicare PIN