Provider Demographics
NPI:1629032776
Name:TANNER, DAVID E (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:TANNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 RED HILL RD
Mailing Address - Street 2:P.O. BOX 10
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-8708
Mailing Address - Country:US
Mailing Address - Phone:717-567-7884
Mailing Address - Fax:
Practice Address - Street 1:82 RED HILL RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8708
Practice Address - Country:US
Practice Address - Phone:717-567-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOSOO4411L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005986020003Medicaid
PW080031059OtherPALMETTA GBA
PATA148070OtherHIGHMARK BLUE SHIELD
PA01014602OtherCAPITAL BLUE CROSS
PW080031059OtherPALMETTA GBA
PA01014602OtherCAPITAL BLUE CROSS