Healthcare Provider Details

I. General information

NPI: 1407078884
Provider Name (Legal Business Name): CLAYTON GRAY LANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 SPRING HILL AVE FL 3
MOBILE AL
36604-1410
US

IV. Provider business mailing address

1720 SPRING HILL AVE FL 3
MOBILE AL
36604-1410
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-2663
  • Fax:
Mailing address:
  • Phone: 251-435-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD.28325
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number28325
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: