Provider Demographics
NPI:1427360445
Name:GATES, TANNER CALVIN (OD)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:CALVIN
Last Name:GATES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-2150
Mailing Address - Country:US
Mailing Address - Phone:402-413-3531
Mailing Address - Fax:402-413-3535
Practice Address - Street 1:5401 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2150
Practice Address - Country:US
Practice Address - Phone:402-413-3531
Practice Address - Fax:402-413-3535
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1362152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096555007OtherMEDICARE PROVIDER NUMBER