Provider Demographics
NPI:1962488841
Name:TANNER, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 HEDGEMORE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4539 HEDGEMORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3276
Practice Address - Country:US
Practice Address - Phone:704-331-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962488841Medicaid
NC8981549Medicaid
SCN35529Medicaid
NCNCG134BMedicare PIN
NC1962488841Medicaid
NCNCG134AMedicare PIN
SCN35529Medicaid