Healthcare Provider Details

I. General information

NPI: 1023087467
Provider Name (Legal Business Name): SANDRA EVELYN LANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA LANE JOSEPH MD

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E OLYMPIA AVE UNIT 211
PUNTA GORDA FL
33950-3823
US

IV. Provider business mailing address

315 E OLYMPIA AVE UNIT 211
PUNTA GORDA FL
33950-3823
US

V. Phone/Fax

Practice location:
  • Phone: 941-637-2663
  • Fax: 941-637-6872
Mailing address:
  • Phone: 941-637-2663
  • Fax: 941-637-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35052191
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME136355
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: