Provider Demographics
NPI:1962862318
Name:DEDRICK, LANE K (DO)
Entity Type:Individual
Prefix:DR
First Name:LANE
Middle Name:K
Last Name:DEDRICK
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 1:3770 SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-6973
Mailing Address - Country:US
Mailing Address - Phone:714-851-2220
Mailing Address - Fax:
Practice Address - Street 1:1300 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3342
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS2975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program