Provider Demographics
NPI:1124079447
Name:LANE, DERRICK F (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:F
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:P.O. BOX 28170
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8170
Mailing Address - Country:US
Mailing Address - Phone:478-254-5943
Mailing Address - Fax:478-254-6093
Practice Address - Street 1:818 FORSYTH STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2139
Practice Address - Country:US
Practice Address - Phone:478-633-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA155203137BMedicaid
GA155203137CMedicaid
GAP00Q81500OtherRR MEDICARE
GA155203137CMedicaid
GA08CBBHPMedicare PIN
I28133Medicare UPIN
GA155203137BMedicaid