Provider Demographics
NPI:1043254931
Name:LANE, GERALD W (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:LANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5250 BETHEL REED PARK
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-1811
Mailing Address - Country:US
Mailing Address - Phone:614-451-8770
Mailing Address - Fax:614-451-2291
Practice Address - Street 1:1275 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3119
Practice Address - Country:US
Practice Address - Phone:614-946-3588
Practice Address - Fax:614-204-3884
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752672Medicaid
OHE62222Medicare UPIN
OH0752672Medicaid