Provider Demographics
NPI:1548253925
Name:TIDAL, ABUBAKAR H (MD)
Entity type:Individual
Prefix:
First Name:ABUBAKAR
Middle Name:H
Last Name:TIDAL
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 1:214 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-7627
Mailing Address - Country:US
Mailing Address - Phone:606-633-3631
Mailing Address - Fax:606-633-6204
Practice Address - Street 1:214 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7627
Practice Address - Country:US
Practice Address - Phone:606-633-3631
Practice Address - Fax:606-633-6204
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64191216Medicaid
C65560Medicare UPIN
KY64191216Medicaid