Provider Demographics
NPI:1417210352
Name:TIDWELL, BRETT R (DO)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:R
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-267-2961
Mailing Address - Fax:850-622-5634
Practice Address - Street 1:27 MACK BAYOU LOOP
Practice Address - Street 2:STE 2000
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2613
Practice Address - Country:US
Practice Address - Phone:850-267-2961
Practice Address - Fax:850-622-5634
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2016-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS13152207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology