Provider Demographics
NPI:1760580476
Name:TIDBALL, JOHN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:TIDBALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23415 THREE NOTCH RD
Mailing Address - Street 2:SUITE 2054
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-4017
Mailing Address - Country:US
Mailing Address - Phone:301-737-7833
Mailing Address - Fax:301-737-4865
Practice Address - Street 1:23415 THREE NOTCH RD
Practice Address - Street 2:SUITE 2054 WILDEWOOD CENTER
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4017
Practice Address - Country:US
Practice Address - Phone:301-737-7833
Practice Address - Fax:301-737-4865
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD52196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1389505000Medicaid
MDG61586Medicare UPIN