Provider Demographics
NPI:1457454043
Name:LANE, CONNIE JO (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4111 S DARLINGTON AVE
Mailing Address - Street 2:#425
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-742-2069
Mailing Address - Fax:918-712-9883
Practice Address - Street 1:4111 S DARLINGTON AVE
Practice Address - Street 2:#425
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-742-2069
Practice Address - Fax:918-712-9883
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK14769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D34919Medicare UPIN