Provider Demographics
NPI:1962486498
Name:LANE, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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 1:500 W BROWN DEER RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W BROWN DEER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217-1618
Practice Address - Country:US
Practice Address - Phone:414-434-0461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI375032085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology