Provider Demographics
NPI:1164465167
Name:LANE, BENJAMIN CLARENCE (OD, MPH, FAAO, FACN)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:CLARENCE
Last Name:LANE
Suffix:
Gender:M
Credentials:OD, MPH, FAAO, FACN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 N BEVERWYCK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-2502
Mailing Address - Country:US
Mailing Address - Phone:973-335-0111
Mailing Address - Fax:973-335-2882
Practice Address - Street 1:16 N BEVERWYCK RD
Practice Address - Street 2:
Practice Address - City:LAKE HIAWATHA
Practice Address - State:NJ
Practice Address - Zip Code:07034-2502
Practice Address - Country:US
Practice Address - Phone:973-335-0111
Practice Address - Fax:973-541-1649
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA263500152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26833Medicare UPIN
NJLA521233Medicare ID - Type Unspecified
NYC144I1Medicare ID - Type Unspecified