Provider Demographics
NPI:1104093962
Name:LANE, TIMOTHY ALBERT (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALBERT
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 1:17 WILLS POINT RD
Mailing Address - Street 2:
Mailing Address - City:MONTAUK
Mailing Address - State:NY
Mailing Address - Zip Code:11954-5198
Mailing Address - Country:US
Mailing Address - Phone:850-491-2319
Mailing Address - Fax:
Practice Address - Street 1:17 WILLS POINT RD
Practice Address - Street 2:
Practice Address - City:MONTAUK
Practice Address - State:NY
Practice Address - Zip Code:11954-5198
Practice Address - Country:US
Practice Address - Phone:850-491-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264019800Medicaid
FL264019800Medicaid