Healthcare Provider Details

I. General information

NPI: 1689060139
Provider Name (Legal Business Name): TANNER CODY CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 RIVERWAY PLACE
BEDFORD, NH 03110 NH
03110
US

IV. Provider business mailing address

703 RIVERWAY PLACE
BEDFORD, NH 03110 NH
03110
US

V. Phone/Fax

Practice location:
  • Phone: 603-627-1661
  • Fax: 603-669-6944
Mailing address:
  • Phone: 603-627-1661
  • Fax: 603-669-6944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60961230
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24268
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: