Provider Demographics
NPI:1659580603
Name:TANKO, QUENTIN K (MD)
Entity Type:Individual
Prefix:
First Name:QUENTIN
Middle Name:K
Last Name:TANKO
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:PO BOX 748249
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2245
Practice Address - Country:US
Practice Address - Phone:352-336-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088628207X00000X
IN01059962207X00000X
WI67408207X00000X
WV23161207X00000X
MN60598207X00000X, 207XX0801X
FLME139915207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000654277OtherANTHEM
IN200513140Medicaid
WV0009333000Medicaid
IN000000654277OtherANTHEM
OTH001Medicare UPIN
WV0009333000Medicaid
IN200513140Medicaid