Provider Demographics
NPI:1407872328
Name:LANE, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
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:PO BOX 25437
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5437
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-855-3765
Practice Address - Street 1:3222 W AZEELE ST
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33622-5437
Practice Address - Country:US
Practice Address - Phone:813-872-8491
Practice Address - Fax:813-872-7766
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23701208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D53689Medicare UPIN