Basic Information
| Provider Information | |||||||||
| NPI: | 1184885519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 729 N MEDICAL CENTER DR W | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593200531 | ||||||||
| FaxNumber: | 5593200539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | A137400 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | A137400 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.