MEDICARE: DR. JOHN R TANNER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1935	AZ

General Provider Information

NPI Number	:	1255337911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN R TANNER OD

Provider Business Mailing Address
First Line	:	18431 N 91ST AVE
Second Line	:	SUITE 1
City	:	PEORIA
State	:	AZ
Zip	:	85382-0817
Country	:	US
Telephone Number	:	623-933-6586
Fax Number	:	623-933-9320

Provider Business Practice Location Address
First Line	:	18431 N 91ST AVE
Second Line	:	SUITE 1
City	:	PEORIA
State	:	AZ
Zip	:	85382-0817
Country	:	US
Telephone Number	:	623-933-6586
Fax Number	:	623-933-9320

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	09/30/2014

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