Basic Information
| Provider Information | |||||||||
| NPI: | 1043627292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 754 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847705504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
| FaxNumber: | 4356741601 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SAINT FRANCIS DR STE 510 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192725236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2014 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5593046-0501 | UT | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 074484 | IA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.