Healthcare Provider Details

I. General information

NPI: 1043390172
Provider Name (Legal Business Name): JOHN SHACKELFORD LANE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR MAILCODE 7403
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

200 WEST ARBOR DRIVE MAILCODE 7403
SAN DIEGO CA
92103-7403
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7404
  • Fax: 858-657-5033
Mailing address:
  • Phone: 858-657-7404
  • Fax: 858-657-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number000000G81602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: