Healthcare Provider Details

I. General information

NPI: 1972399004
Provider Name (Legal Business Name): TANNER WILLIFORD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 NW SAMARITAN DR
CORVALLIS OR
97330-5472
US

IV. Provider business mailing address

72 S COUNTRY LN
FRUIT HEIGHTS UT
84037-2274
US

V. Phone/Fax

Practice location:
  • Phone: 661-578-7111
  • Fax:
Mailing address:
  • Phone: 661-578-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO231412
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: