Provider Demographics
NPI:1205902749
Name:TIDWELL, REX WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:REX
Middle Name:WALLACE
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11811 GA HIGHWAY 74
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-7409
Mailing Address - Country:US
Mailing Address - Phone:478-994-9877
Mailing Address - Fax:478-992-9362
Practice Address - Street 1:1601 WATSON BLVD.
Practice Address - Street 2:HOUSTON MEDICAL CENTER
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093
Practice Address - Country:US
Practice Address - Phone:478-542-7996
Practice Address - Fax:478-542-7943
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GA0103002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46338Medicare UPIN