Provider Demographics
NPI:1447437280
Name:TANNER, DAVID A (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:TANNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-5512
Mailing Address - Country:US
Mailing Address - Phone:937-578-2417
Mailing Address - Fax:
Practice Address - Street 1:500 LONDON AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5512
Practice Address - Country:US
Practice Address - Phone:937-578-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340069422083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2091696Medicaid
G80314Medicare UPIN
7264471Medicare PIN