Provider Demographics
NPI:1942595624
Name:LANE, LESLIE ANN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:LANE
Suffix:
Gender:F
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:P.O. BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623
Mailing Address - Country:US
Mailing Address - Phone:510-535-2965
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:2451 E. 12TH STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3425
Practice Address - Country:US
Practice Address - Phone:510-535-3319
Practice Address - Fax:510-535-4187
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA124958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program