Provider Demographics
NPI:1689060139
Name:CLARK, TANNER CODY (MD)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:CODY
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:703 RIVERWAY PLACE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD, NH 03110
Mailing Address - State:NH
Mailing Address - Zip Code:03110
Mailing Address - Country:US
Mailing Address - Phone:603-627-1661
Mailing Address - Fax:603-669-6944
Practice Address - Street 1:703 RIVERWAY PLACE
Practice Address - Street 2:
Practice Address - City:BEDFORD, NH 03110
Practice Address - State:NH
Practice Address - Zip Code:03110
Practice Address - Country:US
Practice Address - Phone:603-627-1661
Practice Address - Fax:603-669-6944
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD609612302085R0202X
NH242682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology