Provider Demographics
NPI:1265464366
Name:LANE, BENNIE W (MD)
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:W
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7777 FOREST LANE
Mailing Address - Street 2:#A 214
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-0000
Mailing Address - Country:US
Mailing Address - Phone:972-566-7860
Mailing Address - Fax:972-566-6673
Practice Address - Street 1:7777 FOREST LANE
Practice Address - Street 2:#A 214
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-0000
Practice Address - Country:US
Practice Address - Phone:972-566-7860
Practice Address - Fax:972-566-6673
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXD41902086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C18133Medicare UPIN
TX00A81VMedicare PIN