Provider Demographics
NPI:1134681158
Name:BROWN, TANNER WILLIAM
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:WILLIAM
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01944-1704
Mailing Address - Country:US
Mailing Address - Phone:978-526-4800
Mailing Address - Fax:
Practice Address - Street 1:195 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01944-1704
Practice Address - Country:US
Practice Address - Phone:978-526-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1013315207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program