Provider Demographics
NPI:1871556506
Name:TISDALL, CATHERINE M (MD)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:M
Last Name:TISDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8431 FREDERICKSBURG RD
Mailing Address - Street 2:#100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3392
Mailing Address - Country:US
Mailing Address - Phone:210-615-7171
Mailing Address - Fax:210-615-6793
Practice Address - Street 1:8431 FREDERICKSBURG RD
Practice Address - Street 2:#100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3392
Practice Address - Country:US
Practice Address - Phone:210-615-7171
Practice Address - Fax:210-615-6793
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5220207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00605100OtherMEDICARE RR
TX8X5051OtherBCBS
TXM5220OtherLICENSE
TX207N00000XOtherTAXONOMONY
TX742935457OtherTAX ID
TXDG9652OtherMEDICARE RR GROUP PTAN
TX00203VOtherMEDICARE PTAN GROUP
TXI50749Medicare UPIN
TX8J4999Medicare PIN