Provider Demographics
NPI:1629041728
Name:TANKSLEY, RADFORD DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RADFORD
Middle Name:DOUGLAS
Last Name:TANKSLEY
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 1:111 SALEM TPKE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6459
Mailing Address - Country:US
Mailing Address - Phone:860-859-2262
Mailing Address - Fax:
Practice Address - Street 1:111 SALEM TPKE
Practice Address - Street 2:SUITE 7
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6459
Practice Address - Country:US
Practice Address - Phone:860-859-2262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030170207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP00332772OtherRAILROAD
CT010030170CT02OtherANTHEM BCBS
CT030170Medicaid
CTP00332772OtherRAILROAD
CTD98356Medicare UPIN