Healthcare Provider Details

I. General information

NPI: 1346247053
Provider Name (Legal Business Name): LANE E JENNINGS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CLYDE MORRIS BLVD STE 200
DAYTONA BEACH FL
32114-2765
US

IV. Provider business mailing address

PO BOX 864074
ORLANDO FL
32886-4074
US

V. Phone/Fax

Practice location:
  • Phone: 386-254-4165
  • Fax: 386-254-4339
Mailing address:
  • Phone: 386-226-4590
  • Fax: 386-226-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0035449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: