MEDICARE: WELDON TANNER DO

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	207P00000X	Emergency Medicine Physician	0054	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0054	OTHER	OK	RESIDENT IN TRAINING

General Provider Information

NPI Number	:	1861800716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WELDON TANNER DO

Provider Business Mailing Address
First Line	:	4401 SW 44TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-2899
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 SW 44TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-2899
Country	:	US
Telephone Number	:	405-636-7195
Fax Number	:

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

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	07/23/2014

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Directions to “ WELDON TANNER DO” Practice Location

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