Provider Demographics
NPI:1679888606
Name:TISDALE, BRITTON EDGETT (MD, BSCPHM)
Entity type:Individual
Prefix:DR
First Name:BRITTON
Middle Name:EDGETT
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MD, BSCPHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 NATURE COVE CT
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1978
Mailing Address - Country:US
Mailing Address - Phone:716-319-8113
Mailing Address - Fax:
Practice Address - Street 1:36 NATURE COVE CT
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14221-1978
Practice Address - Country:US
Practice Address - Phone:716-319-8113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-14
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116021688208800000X
NY003851208800000X
NY271542208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1916947OtherIHA
NY652569OtherWELLCARE
NY3383479Medicaid
NY533379001OtherBLUE CROSS
NY29695201OtherUNIVERA
NY533379001OtherBLUE CROSS