Provider Demographics
NPI:1780098756
Name:TIDWELL, NATHAN (DO)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT EISENHOWER
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-8668
Mailing Address - Fax:706-787-7136
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-8668
Practice Address - Fax:706-787-7136
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075019207R00000X
GA75019207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine