Provider Demographics
NPI:1801258611
Name:MATHIAS, TANNER DUANE (MD)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:DUANE
Last Name:MATHIAS
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 1:160 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:802-772-2460
Mailing Address - Fax:802-772-2556
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-772-2460
Practice Address - Fax:802-772-2556
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0059517207Q00000X, 208M00000X
COTL.0006164207Q00000X
VT042.0014423207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine