Basic Information
| Provider Information | |||||||||
| NPI: | 1649414525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISDALE | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX PH | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865038000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 191 AND HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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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 | 35.121001 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35.121001 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.