Provider Demographics
NPI:1962473975
Name:TIDMORE, HOLLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLIS
Middle Name:
Last Name:TIDMORE
Suffix:
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 1:1422 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2130
Mailing Address - Country:US
Mailing Address - Phone:417-967-1252
Mailing Address - Fax:417-967-0417
Practice Address - Street 1:1422 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2130
Practice Address - Country:US
Practice Address - Phone:417-967-1252
Practice Address - Fax:417-967-0417
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090058972086S0129X, 208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207050501Medicaid
NCB92694Medicare UPIN