Provider Demographics
NPI:1609897578
Name:TANNER, DAVID ERIC (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ERIC
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 1:5387 MANHATTAN CIR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4284
Mailing Address - Country:US
Mailing Address - Phone:303-494-2705
Mailing Address - Fax:303-494-2706
Practice Address - Street 1:5387 MANHATTAN CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4284
Practice Address - Country:US
Practice Address - Phone:303-494-2705
Practice Address - Fax:303-494-2706
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38635204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
COH32430Medicare UPIN
COC807492Medicare PIN
COC807341Medicare PIN
COC807331Medicare PIN