Provider Demographics
NPI:1932337052
Name:FREY, LANE MIKAEL (MD)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:MIKAEL
Last Name:FREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-493-4578
Mailing Address - Fax:
Practice Address - Street 1:726 N ACADIA RD.
Practice Address - Street 2:STE 3300
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-493-3080
Practice Address - Fax:985-493-3081
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.205457207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1894192Medicaid
LA369415ZJW2Medicare PIN