Provider Demographics
NPI:1043203409
Name:LANE, JOEY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOEY
Middle Name:LYNN
Last Name:LANE
Suffix:
Gender:M
Credentials:OD
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 697
Mailing Address - Street 2:
Mailing Address - City:MC CONNELLSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17233-0697
Mailing Address - Country:US
Mailing Address - Phone:717-485-4434
Mailing Address - Fax:717-485-9407
Practice Address - Street 1:182 BUCHANAN TRAIL
Practice Address - Street 2:SUITE 185
Practice Address - City:MCCONNELLSBURG
Practice Address - State:PA
Practice Address - Zip Code:17233-8261
Practice Address - Country:US
Practice Address - Phone:717-485-4434
Practice Address - Fax:717-485-9407
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOGE000013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014884720003Medicaid
PA50075089OtherCAPITAL BLUE CROSS
PA0014884720003Medicaid
PA50075089OtherCAPITAL BLUE CROSS
PA6072760001Medicare NSC