Provider Demographics
NPI:1912165317
Name:LANE, MARY KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ROBINSON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6275
Mailing Address - Country:US
Mailing Address - Phone:678-633-3260
Mailing Address - Fax:678-633-3278
Practice Address - Street 1:61 ROBINSON LAKE RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6275
Practice Address - Country:US
Practice Address - Phone:678-633-3260
Practice Address - Fax:678-633-3278
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72292207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine