Provider Demographics
NPI:1568850543
Name:LANE, TIMOTHY GERALD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GERALD
Last Name:LANE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-6611
Mailing Address - Country:US
Mailing Address - Phone:321-591-9229
Mailing Address - Fax:407-552-4197
Practice Address - Street 1:1393 GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-6611
Practice Address - Country:US
Practice Address - Phone:321-591-9229
Practice Address - Fax:407-552-4197
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43204207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology