Basic Information
| Provider Information | |||||||||
| NPI: | 1275972325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. CHURCH STREET | ||||||||
| Address2: | ATTENTION: MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393954 | ||||||||
| FaxNumber: | 8057393060 | ||||||||
| Practice Location | |||||||||
| Address1: | 5920 WEST MALL | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054660676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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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 | 207R00000X | DR.0056805 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.