Provider Demographics
NPI:1952337990
Name:TANNER, JOHN CALVIN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CALVIN
Last Name:TANNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51595
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32240-1595
Mailing Address - Country:US
Mailing Address - Phone:904-571-9439
Mailing Address - Fax:904-758-0559
Practice Address - Street 1:340 16TH AVE N STE A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4819
Practice Address - Country:US
Practice Address - Phone:904-241-2653
Practice Address - Fax:904-758-0559
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0004709207Q00000X, 207QA0401X
FLOS47092084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010659200Medicaid
FL068895900Medicaid
FL080025596OtherMEDICARE RAILROAD
FL82622OtherBCBS
FL82622OtherBCBS
FL068895900Medicaid
FL82622YMedicare PIN