Individual
LUCAS TIDWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
22250 PROVIDENCE DR STE 206, SOUTHFIELD, MI 48075-6210
(248) 662-4333
Mailing address
22250 PROVIDENCE DR STE 206, SOUTHFIELD, MI 48075-6210
(248) 662-4333
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
4301514131
MI
Other
Enumeration date
03/24/2020
Last updated
07/08/2025
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