Healthcare Provider Details

I. General information

NPI: 1255337911
Provider Name (Legal Business Name): JOHN R TANNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18431 N 91ST AVE SUITE 1
PEORIA AZ
85382-0817
US

IV. Provider business mailing address

18431 N 91ST AVE SUITE 1
PEORIA AZ
85382-0817
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-6586
  • Fax: 623-933-9320
Mailing address:
  • Phone: 623-933-6586
  • Fax: 623-933-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: