Provider Demographics
NPI:1275974909
Name:TIDWELL, CRYSTAL C (DO)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:C
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:DO
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 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-278-3920
Mailing Address - Fax:850-278-3919
Practice Address - Street 1:23 MACK BAYOU LOOP
Practice Address - Street 2:STE 200
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2606
Practice Address - Country:US
Practice Address - Phone:850-278-3920
Practice Address - Fax:850-278-3919
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14104208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics