Provider Demographics
NPI:1538149216
Name:TIDWELL, STEVEN M (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:M
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 1:52 SAINT THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4598
Mailing Address - Country:US
Mailing Address - Phone:561-625-1626
Mailing Address - Fax:
Practice Address - Street 1:5155 CORPORATE WAY STE A
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4359
Practice Address - Country:US
Practice Address - Phone:561-624-0123
Practice Address - Fax:561-624-1453
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 624772085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF34516Medicare UPIN
FL17806QMedicare ID - Type Unspecified