Individual
JUSTIN ALAN TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
501 N GRAHAM ST, SUITE 415, PORTLAND, OR 97227-1654
(503) 413-2005
(503) 413-3699
Mailing address
5815 NE 23RD AVE, PORTLAND, OR 97211-5447
(503) 936-7454
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
DP00373
OR
213ES0103X
Foot & Ankle Surgery Podiatrist
PO00000806
WA
Other
Enumeration date
07/22/2006
Last updated
07/08/2007
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