Healthcare Provider Details

I. General information

NPI: 1730686841
Provider Name (Legal Business Name): LANCE MIDDLETON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PARNASSUS AVE
SAN FRANCISCO CA
94143-0984
US

IV. Provider business mailing address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-7527
  • Fax: 415-476-7722
Mailing address:
  • Phone: 225-335-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA166701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: