Provider Demographics
NPI:1619979044
Name:LANE, KEVIN B (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
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:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-0359
Mailing Address - Country:US
Mailing Address - Phone:940-663-5111
Mailing Address - Fax:940-663-5288
Practice Address - Street 1:404 MERCER ST
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252-4026
Practice Address - Country:US
Practice Address - Phone:940-663-5111
Practice Address - Fax:940-663-5288
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D1187Medicare ID - Type Unspecified
TXE87143Medicare UPIN