Provider Demographics
NPI:1578516779
Name:LANE, RANDALL BRENT (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:BRENT
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 1:8350 MEADOW RD
Mailing Address - Street 2:266
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3768
Mailing Address - Country:US
Mailing Address - Phone:214-363-5115
Mailing Address - Fax:214-363-2740
Practice Address - Street 1:8350 MEADOW RD
Practice Address - Street 2:266
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3768
Practice Address - Country:US
Practice Address - Phone:214-363-5115
Practice Address - Fax:214-363-2740
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE26672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC18132Medicare UPIN
TX00FT32Medicare ID - Type Unspecified