Healthcare Provider Details

I. General information

NPI: 1770570426
Provider Name (Legal Business Name): LEO WILLIAM LANE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 MERRIMACK ST SUITE 201
METHUEN MA
01844-5803
US

IV. Provider business mailing address

421 MERRIMACK ST SUITE 201
METHUEN MA
01844-5803
US

V. Phone/Fax

Practice location:
  • Phone: 978-725-4822
  • Fax: 978-725-5277
Mailing address:
  • Phone: 978-725-4822
  • Fax: 978-725-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number155341
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: