Provider Demographics
NPI:1962023754
Name:TISDALE, NICHOLAS E (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:TISDALE
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 1:2351 SW MARTIN HWY
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3222
Mailing Address - Country:US
Mailing Address - Phone:772-324-9337
Mailing Address - Fax:772-324-9347
Practice Address - Street 1:2351 SW MARTIN HWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3222
Practice Address - Country:US
Practice Address - Phone:772-324-9337
Practice Address - Fax:772-324-9347
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME169907207R00000X
NV22993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine