Healthcare Provider Details

I. General information

NPI: 1801100375
Provider Name (Legal Business Name): JERRY W TANNER M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S 70TH ST SUITE 200
LINCOLN NE
68510-4293
US

IV. Provider business mailing address

1101 S 70TH ST SUITE 200
LINCOLN NE
68510-4293
US

V. Phone/Fax

Practice location:
  • Phone: 402-486-3132
  • Fax: 402-486-3187
Mailing address:
  • Phone: 402-486-3132
  • Fax: 402-486-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14880
License Number StateNE

VIII. Authorized Official

Name: JERRY TANNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 402-486-3132