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General NPI Number Information
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NPI Number | 1689060139
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Entity Type | Individual
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Provider Name | TANNER CODY CLARK M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/11/2015
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Last Update Date | 09/08/2023
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Provider Practice Location Address
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Address Line | 703 RIVERWAY PLACE
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City | BEDFORD, NH 03110
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State | NH
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Zip | 03110
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Country | US
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Telephone | 603-627-1661
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Fax | 603-669-6944
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Provider Business Mailing Address
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Address Line | 703 RIVERWAY PLACE
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City | BEDFORD, NH 03110
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State | NH
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Zip | 03110
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Country | US
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Telephone | 603-627-1661
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Fax | 603-669-6944
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD60961230
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 24268
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License Number State | NH
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