Provider Demographics
NPI:1538171376
Name:LANE, WILLIAM KELVIN (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KELVIN
Last Name:LANE
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 1:1950 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1575
Mailing Address - Country:US
Mailing Address - Phone:229-883-1508
Mailing Address - Fax:
Practice Address - Street 1:1950 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1575
Practice Address - Country:US
Practice Address - Phone:229-883-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008821208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00016673AMedicaid
GA008821OtherGEORGIA LICENSE NUMBER
GAD70525Medicare UPIN