Provider Demographics
NPI:1912016023
Name:TANNER, DAVID LYON (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LYON
Last Name:TANNER
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 1:1715 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1802
Mailing Address - Country:US
Mailing Address - Phone:801-526-0026
Mailing Address - Fax:
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-993-9551
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188114-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT62239OtherPEHP
UTPRA04909OtherMOLINA
UT2000040OtherUNITED HEALTHCARE
UT260488OtherDESERET MUTUAL
UTQM0000047288OtherALTIUS
AZ706509Medicaid
UT107007959101OtherIHC
UT112017OtherHEALTHY U
MT401765Medicaid
UT870280408TA1OtherEDUCATORS MUTUAL
UT112017OtherHEALTHY U