Provider Demographics
NPI:1801072632
Name:TIDWELL, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:TIDWELL
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 1:1800 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4158
Mailing Address - Country:US
Mailing Address - Phone:601-703-9544
Mailing Address - Fax:601-703-9295
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-9544
Practice Address - Fax:601-703-9295
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS193582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology