Provider Demographics
NPI:1467740225
Name:LANE, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:612 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4702
Mailing Address - Country:US
Mailing Address - Phone:479-785-2431
Mailing Address - Fax:479-494-7787
Practice Address - Street 1:1301 S E ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4716
Practice Address - Country:US
Practice Address - Phone:479-785-2431
Practice Address - Fax:479-494-7787
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR189401001Medicaid
OK200341230AMedicaid
AR5AM58G4347231Medicare PIN