Healthcare Provider Details

I. General information

NPI: 1699741082
Provider Name (Legal Business Name): ROBERT C LANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 GRASSE STREET
CALICO ROCK AR
72519
US

IV. Provider business mailing address

PO BOX 819
CALICO ROCK AR
72519-0819
US

V. Phone/Fax

Practice location:
  • Phone: 870-297-2475
  • Fax: 870-297-4380
Mailing address:
  • Phone: 870-297-2475
  • Fax: 870-297-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC4350
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC4350
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: