Provider Demographics
NPI:1922099670
Name:TIDWELL, DAVID JOSHUA (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSHUA
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25327 INTERSTATE 45
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3521
Mailing Address - Country:US
Mailing Address - Phone:936-207-4154
Mailing Address - Fax:281-825-3660
Practice Address - Street 1:25327 INTERSTATE 45
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3521
Practice Address - Country:US
Practice Address - Phone:936-207-4154
Practice Address - Fax:936-207-4154
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT7173225100000X
TX1230520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3659498Medicaid
TN3659498Medicare PIN