Provider Demographics
NPI:1396715751
Name:LANE, LARRY H (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:H
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 218
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:OK
Mailing Address - Zip Code:74016-0218
Mailing Address - Country:US
Mailing Address - Phone:918-789-3146
Mailing Address - Fax:
Practice Address - Street 1:403 REDBUD LN
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:OK
Practice Address - Zip Code:74016-1453
Practice Address - Country:US
Practice Address - Phone:918-789-3146
Practice Address - Fax:918-789-5650
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD38554Medicare UPIN