Provider Demographics
NPI:1952744021
Name:TANNER, IMA SUMAC DUCHICELA (MD)
Entity Type:Individual
Prefix:
First Name:IMA SUMAC
Middle Name:DUCHICELA
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IMA SUMAC
Other - Middle Name:
Other - Last Name:DUCHICELA TANNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3030 WATERVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-1400
Mailing Address - Country:US
Mailing Address - Phone:972-669-7070
Mailing Address - Fax:
Practice Address - Street 1:3030 WATERVIEW PKWY
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080
Practice Address - Country:US
Practice Address - Phone:972-669-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine