Provider Demographics
NPI:1184758526
Name:TIDWELL, PAT THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:PAT
Middle Name:THOMAS
Last Name:TIDWELL
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 1:4400 E HIGHWAY 20 STE 203
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-7700
Mailing Address - Country:US
Mailing Address - Phone:850-897-3678
Mailing Address - Fax:850-373-4544
Practice Address - Street 1:4400 E HIGHWAY 20 STE 203
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7700
Practice Address - Country:US
Practice Address - Phone:850-897-3678
Practice Address - Fax:850-373-4544
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46132Medicare ID - Type Unspecified
FLD54957Medicare UPIN