Provider Demographics
NPI:1932151792
Name:TANNER, CHRISTOPHER D (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:151 E REDSTONE AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5352
Practice Address - Country:US
Practice Address - Phone:850-650-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65153207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23573OtherBCBS
FL374014500Medicaid
FL23573TMedicare PIN
FL23573OtherBCBS
FL374014500Medicaid
FL23573DMedicare ID - Type Unspecified
FL374014500Medicare ID - Type Unspecified
FLP00445078Medicare PIN
FLP00283680Medicare PIN
FL23573FMedicare PIN