Provider Demographics
NPI:1316986631
Name:MILLER, LANE R (MD)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:R
Last Name:MILLER
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 1:1721 BIRMINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4082
Mailing Address - Country:US
Mailing Address - Phone:979-764-1474
Mailing Address - Fax:979-764-9249
Practice Address - Street 1:1721 BIRMINGHAM DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-4082
Practice Address - Country:US
Practice Address - Phone:979-764-1474
Practice Address - Fax:979-764-9249
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ115OtherBLUE CROSS
TXH23965Medicare UPIN
TX8AJ115OtherBLUE CROSS