Provider Demographics
NPI:1568441616
Name:TANNER, RONALD DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:DOUGLAS
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 1:4421 OAK PARK LN STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-9541
Mailing Address - Country:US
Mailing Address - Phone:817-732-2878
Mailing Address - Fax:817-732-9315
Practice Address - Street 1:4421 OAK PARK LN STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-9541
Practice Address - Country:US
Practice Address - Phone:817-732-2878
Practice Address - Fax:817-732-9315
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8515207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040573013Medicaid
TX040573014Medicaid
TX040573016Medicaid
TXP00005154OtherRAILROAD MEDICARE
TX8A3354OtherBCBS
TX040573015Medicaid
TXP00005154OtherRAILROAD MEDICARE
TX040573015Medicaid
TX8A3354OtherBCBS
TX8L11705Medicare PIN
TX8L11703Medicare PIN