Provider Demographics
NPI:1699879874
Name:TIDMORE, TAYLOR REED (MD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:REED
Last Name:TIDMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2932
Mailing Address - Country:US
Mailing Address - Phone:325-437-3687
Mailing Address - Fax:325-437-1827
Practice Address - Street 1:1233 N 18TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2932
Practice Address - Country:US
Practice Address - Phone:325-437-3687
Practice Address - Fax:325-437-1827
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2003013847207Y00000X
TXM6917207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196006401Medicaid