Provider Demographics
NPI:1568419216
Name:TIDWELL, LESLIE G (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1867
Mailing Address - Country:US
Mailing Address - Phone:478-405-0045
Mailing Address - Fax:478-405-0054
Practice Address - Street 1:3448 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1867
Practice Address - Country:US
Practice Address - Phone:478-405-0045
Practice Address - Fax:478-405-0054
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44359207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000866907AMedicaid
GA000866907BMedicaid
GA202I169707OtherMEDICARE ID
GAGRP7599OtherMEDICARE PIN
GA000866907BMedicaid