Provider Demographics
NPI:1154424240
Name:LANE, ROGER I (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:I
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 1:2030 VIBORG ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463-2298
Mailing Address - Country:US
Mailing Address - Phone:805-688-2600
Mailing Address - Fax:805-693-8109
Practice Address - Street 1:2030 VIBORG ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-2298
Practice Address - Country:US
Practice Address - Phone:805-688-2600
Practice Address - Fax:805-693-8109
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G752360Medicaid
G67961Medicare UPIN
WG75236BMedicare ID - Type Unspecified