Provider Demographics
NPI:1659374122
Name:PHILLIPS, LANE R (DO)
Entity Type:Individual
Prefix:DR
First Name:LANE
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:LANE
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1125 TOWNPARK AVE SUITE 1011
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7605
Mailing Address - Country:US
Mailing Address - Phone:407-804-9494
Mailing Address - Fax:407-804-9443
Practice Address - Street 1:1125 TOWNPARK AVE STE 1011
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-7605
Practice Address - Country:US
Practice Address - Phone:407-804-9494
Practice Address - Fax:407-804-9443
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83416207Q00000X
FL0S7692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC83416OtherSC BOARD OF MEDICAL EXAMINERS