Healthcare Provider Details

I. General information

NPI: 1992169437
Provider Name (Legal Business Name): TANNER CALVIN HARRAH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 W COVINA BLVD STE 105
SAN DIMAS CA
91773-3211
US

IV. Provider business mailing address

1334 W COVINA BLVD STE 105
SAN DIMAS CA
91773-3211
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-0881
  • Fax:
Mailing address:
  • Phone: 909-599-0881
  • Fax: 909-394-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20A15819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: