Active NPI
Mark Winston Tidwell, M.D.
- Family Medicine Physician
- Clermont, FL
National Provider Identifier
1730464686
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- ME55805
- Practice address
- 1960 Brantley Cir
Clermont, FL 34711-2900 - Phone
- (352) 689-6103
- NPI assigned
- Oct 11, 2011
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | ME55805 | FL | Primary |
Addresses
Primary practice location
1960 Brantley Cir
Clermont, FL 34711-2900
Mailing address
1960 Brantley Cir
Clermont, FL 34711-2900
Phone (352) 689-6103
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 039568400 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ME55805 | FL | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1318291200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1318291200000",
"number": "1730464686",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1960 BRANTLEY CIR",
"city": "CLERMONT",
"state": "FL",
"postal_code": "347112900",
"telephone_number": "352-689-6103"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1960 BRANTLEY CIR",
"city": "CLERMONT",
"state": "FL",
"postal_code": "347112900",
"telephone_number": "352-689-6103"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIDWELL",
"first_name": "MARK",
"middle_name": "WINSTON",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-10-11",
"last_updated": "2011-10-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "FL",
"license": "ME55805",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "039568400",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Clermont, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.