Provider Demographics
NPI:1750679072
Name:TIDWELL, STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840026
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0026
Mailing Address - Country:US
Mailing Address - Phone:806-212-5079
Mailing Address - Fax:806-212-6278
Practice Address - Street 1:1000 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1781
Practice Address - Country:US
Practice Address - Phone:806-212-4700
Practice Address - Fax:806-212-4730
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9475207PE0005X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty