=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093744096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID RICHEY LANE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15830 BALLANTYNE MEDICAL PLACE STE 225
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-919-1105
-----------------------------------------------------
Fax | 704-910-3163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15830 BALLANTYNE MEDICAL PLACE STE 225
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-919-1105
-----------------------------------------------------
Fax | 704-910-3163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 200600844
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 00844
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 00844
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | 00844
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------