Provider Demographics
NPI:1568451318
Name:TANNER, JAMES WESTLEY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WESTLEY
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 1:1722 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8339
Mailing Address - Country:US
Mailing Address - Phone:386-428-3241
Mailing Address - Fax:386-427-8440
Practice Address - Street 1:1722 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8339
Practice Address - Country:US
Practice Address - Phone:386-428-3241
Practice Address - Fax:386-427-8440
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018256208D00000X
FL95760208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46294Medicare UPIN
GA08BBRHPMedicare ID - Type Unspecified