Provider Demographics
NPI:1093744096
Name:LANE, DAVID RICHEY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHEY
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Mailing Address - Street 2:STE 225
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3294
Mailing Address - Country:US
Mailing Address - Phone:704-919-1105
Mailing Address - Fax:704-910-3163
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Practice Address - Street 2:STE 225
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3294
Practice Address - Country:US
Practice Address - Phone:704-919-1105
Practice Address - Fax:704-910-3163
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600844174400000X
NC00844207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No174400000XOther Service ProvidersSpecialist
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2075624OtherMEDICARE GROUP PTAN
SCAA2608F903Medicare UPIN
NC2075624OtherMEDICARE GROUP PTAN
NC2075624OtherMEDICARE GROUP PTAN