Provider Demographics
NPI:1245291608
Name:LANE, BRYAN L (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:L
Last Name:LANE
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508
Practice Address - Country:US
Practice Address - Phone:254-724-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6535207QS0010X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0486011-01OtherCSHCN
TX080161733OtherRR/MEDICARE
TX1222655-01Medicaid
TX88791NOtherBLUE SHIELD
TX1222655-01Medicaid
TX0486011-01OtherCSHCN