Provider Demographics
NPI:1184612624
Name:TANNER, GARTH B (MD)
Entity type:Individual
Prefix:
First Name:GARTH
Middle Name:B
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:PO BOX 3812
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-3812
Mailing Address - Country:US
Mailing Address - Phone:209-521-7800
Mailing Address - Fax:209-521-1329
Practice Address - Street 1:1429 COLLEGE AVE
Practice Address - Street 2:STE K
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4057
Practice Address - Country:US
Practice Address - Phone:209-521-7800
Practice Address - Fax:209-521-5733
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA64407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A644070Medicaid
CAH05811Medicare UPIN
CA00A644070Medicaid