Provider Demographics
NPI:1306133285
Name:WILLIAM D. TANKE, OD, PA
Entity type:Organization
Organization Name:WILLIAM D. TANKE, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:TANKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-412-3487
Mailing Address - Street 1:2652 GLASBERN CIR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8075
Mailing Address - Country:US
Mailing Address - Phone:321-412-3487
Mailing Address - Fax:
Practice Address - Street 1:1813 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3930
Practice Address - Country:US
Practice Address - Phone:321-951-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078289100Medicaid
T84175Medicare UPIN
FL078289100Medicaid