Healthcare Provider Details

I. General information

NPI: 1861697021
Provider Name (Legal Business Name): CLINT TANNER ALLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 ROCKLEDGE DR SUITE 4920
BETHESDA MD
20817-7837
US

IV. Provider business mailing address

6420 ROCKLEDGE DR SUITE 4920
BETHESDA MD
20817-7837
US

V. Phone/Fax

Practice location:
  • Phone: 301-896-3331
  • Fax:
Mailing address:
  • Phone: 301-896-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD60276311
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101275391
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD76403
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: