Basic Information
| Provider Information | |||||||||
| NPI: | 1104089606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28202 CABOT RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926771249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493655765 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27700 MEDICAL CENTER RD | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493647744 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5876 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0202X | A110702 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A1107020 | 01 | CA | BC/BS OF CA | OTHER | 1104089606 | 05 | CA | MEDICAID |