Provider Demographics
NPI:1235270174
Name:LANE, JUSTIN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
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 1:120 WYNDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-6710
Mailing Address - Country:US
Mailing Address - Phone:910-508-4127
Mailing Address - Fax:
Practice Address - Street 1:1345 WESTERN BLVD STE 120B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7627
Practice Address - Country:US
Practice Address - Phone:910-376-8229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist