Provider Demographics
NPI:1235779463
Name:LANE, DAVID HUBBELL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:HUBBELL
Last Name:LANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40849 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4306
Mailing Address - Country:US
Mailing Address - Phone:510-825-7722
Mailing Address - Fax:
Practice Address - Street 1:712 ASHBURY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-4014
Practice Address - Country:US
Practice Address - Phone:415-362-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver