Provider Demographics
NPI:1609181148
Name:TANNER, BRYCE (OD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:TANNER
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:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-0820
Mailing Address - Country:US
Mailing Address - Phone:970-565-2020
Mailing Address - Fax:970-565-3632
Practice Address - Street 1:140 NORTH MARKET ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:970-565-2020
Practice Address - Fax:970-565-3632
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist