Provider Demographics
NPI:1841282498
Name:LANE, GARY E (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:E
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 1:1925 E ORMAN AVE
Mailing Address - Street 2:SUITE A109
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-564-0210
Mailing Address - Fax:719-564-9483
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE A109
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-0210
Practice Address - Fax:719-564-9483
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35242208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01352426Medicaid
COK9648Medicare ID - Type Unspecified
F71176Medicare UPIN