Provider Demographics
NPI:1295701241
Name:TIDMORE, WILLIAM LEWIS (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEWIS
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 1:4311 GRANTS GLN
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-1424
Mailing Address - Country:US
Mailing Address - Phone:940-696-1291
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:SUITE #5
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-1886
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD65502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD000Medicare UPIN