Provider Demographics
NPI:1932327418
Name:TIDBALL, JON MARC (MPT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MARC
Last Name:TIDBALL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1173 WIMBELDON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-9327
Mailing Address - Country:US
Mailing Address - Phone:614-946-1669
Mailing Address - Fax:614-293-7540
Practice Address - Street 1:551 YMCA PL
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6851
Practice Address - Country:US
Practice Address - Phone:614-293-7600
Practice Address - Fax:614-293-7540
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11384225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist