Provider Demographics
NPI:1083602338
Name:LANE, JILL (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:A
Other - Last Name:ADDESA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8879
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:MAILDROP 203N
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-8879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88121207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70502Medicare UPIN