Provider Demographics
NPI:1043390172
Name:LANE, JOHN SHACKELFORD III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SHACKELFORD
Last Name:LANE
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:200 WEST ARBOR DRIVE
Mailing Address - Street 2:MAILCODE 7403
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-7403
Mailing Address - Country:US
Mailing Address - Phone:858-657-7404
Mailing Address - Fax:858-657-5033
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:MAILCODE 7403
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:858-657-7404
Practice Address - Fax:858-657-5033
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA000000G816022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG81602AMedicare PIN
CAH59478Medicare UPIN