Provider Demographics
NPI:1427168525
Name:TIDALGO, RALPH J (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:J
Last Name:TIDALGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4889 OLD POST CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3554
Mailing Address - Country:US
Mailing Address - Phone:248-320-6409
Mailing Address - Fax:
Practice Address - Street 1:26645 W 12 MILE RD
Practice Address - Street 2:STE 109
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7811
Practice Address - Country:US
Practice Address - Phone:248-797-5293
Practice Address - Fax:248-327-7394
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301045963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4284823Medicaid
MI4284823Medicaid
MI0N92810Medicare ID - Type Unspecified