Provider Demographics
NPI:1235206350
Name:TANNER, J LANE (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:LANE
Last Name:TANNER
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 1:747 52ND ST
Mailing Address - Street 2:CHRCO CHILD DEVELOPMENT CENTER
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-428-3351
Mailing Address - Fax:510-601-3912
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:CHRCO CHILD DEVELOPMENT CENTER
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3351
Practice Address - Fax:510-601-3912
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG286112080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095850Medicaid