Provider Demographics
NPI:1881740561
Name:LANE, JOHAN OLOF (MD)
Entity type:Individual
Prefix:DR
First Name:JOHAN
Middle Name:OLOF
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 1:1435 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2120
Mailing Address - Country:US
Mailing Address - Phone:847-832-6500
Mailing Address - Fax:847-724-5379
Practice Address - Street 1:1435 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025
Practice Address - Country:US
Practice Address - Phone:847-832-6500
Practice Address - Fax:847-724-5379
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-132255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18824OtherKAISER COMMERCIAL NUMBER