MEDICARE: DR. CONNIE J LANE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A87503	CA

General Provider Information

NPI Number	:	1467534750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONNIE J LANE M.D.

Provider Business Mailing Address
First Line	:	11080 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1937
Country	:	US
Telephone Number	:	310-966-6523
Fax Number	:	310-231-0764

Provider Business Practice Location Address
First Line	:	11080 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1937
Country	:	US
Telephone Number	:	310-966-6523
Fax Number	:	310-231-0764

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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