Provider Demographics
NPI:1831119197
Name:ROSEN, LANE RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:RANDALL
Last Name:ROSEN
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:PO BOX 30015
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-0015
Mailing Address - Country:US
Mailing Address - Phone:318-212-4639
Mailing Address - Fax:318-212-8305
Practice Address - Street 1:2600 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3950
Practice Address - Country:US
Practice Address - Phone:318-212-4639
Practice Address - Fax:318-212-8305
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0220042085R0202X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1697192Medicaid
LA4A052CK38Medicare PIN
LAG50435Medicare UPIN
LA4J052CK38Medicare PIN