Provider Demographics
NPI:1528037793
Name:LANE, JACK (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 WHEELER CT
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-0962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:937 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246-0001
Practice Address - Country:US
Practice Address - Phone:559-998-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine