Healthcare Provider Details

I. General information

NPI: 1114918521
Provider Name (Legal Business Name): DANNIE L TABOR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 E COLBY ST
WHITEHALL MI
49461-1262
US

IV. Provider business mailing address

5481 SCENIC DR
WHITEHALL MI
49461-9463
US

V. Phone/Fax

Practice location:
  • Phone: 231-728-5910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101006323
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: