Healthcare Provider Details

I. General information

NPI: 1821798315
Provider Name (Legal Business Name): LANCE MIDDLETON M.D., PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 BRIDGEWAY STE 212
SAUSALITO CA
94965-2898
US

IV. Provider business mailing address

32 LESLIE CT
NOVATO CA
94947-2921
US

V. Phone/Fax

Practice location:
  • Phone: 707-504-9982
  • Fax:
Mailing address:
  • Phone: 225-335-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LANCE MIDDLETON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 225-335-4986