| Doctor Name: | DR. JONATHAN D TIDWELL |
| NPI Number: | 1053574939 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 061763 |
| Business Practice Address: | 2337 Canal Dr Niceville, FL - 325782911 |
| Business Phone Number: | 8134826956 |
| Business Fax Number: | |
| Mailing Address: | 2337 Canal Dr, NICEVILLE |
| State: | FL |
| Postal Code: | 325782911 |
| Phone Number: | 8134826956 |
| Fax Number: | |
| NPI Enumeration Date: | 07/09/2008 |
| NPI Last Update Date: | 11/19/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 061763 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | GA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |