Provider Demographics
NPI:1740297076
Name:TISDALE, AVIAN L (MD)
Entity type:Individual
Prefix:DR
First Name:AVIAN
Middle Name:L
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AVIAN
Other - Middle Name:
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1925 PACIFIC AVE.
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-441-8087
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08575900207P00000X, 208M00000X
TXR7343208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist