Provider Demographics
NPI:1568651388
Name:TIDWELL, NATALIE YAZDANI (MD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:YAZDANI
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 1:1870 EDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2970
Mailing Address - Country:US
Mailing Address - Phone:863-263-7172
Mailing Address - Fax:
Practice Address - Street 1:31 E MACK BAYOU DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7102
Practice Address - Country:US
Practice Address - Phone:863-263-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062443207V00000X
CT048717207V00000X
FLME105686207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT048717OtherMD LICENCE