Provider Demographics
NPI:1942427380
Name:TIDWELL, JAMES ELLIOTT III (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ELLIOTT
Last Name:TIDWELL
Suffix:III
Gender:M
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:2211 MAYFAIR DR STE 305
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4572
Practice Address - Country:US
Practice Address - Phone:270-688-3700
Practice Address - Fax:270-688-3709
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47992208200000X, 2086S0122X, 2086S0122X, 208200000X
TXM6422208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery