Provider Demographics
NPI:1619979044
Name:LANE, KEVIN B (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:B
Last Name:LANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 WILBARGER ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3137
Mailing Address - Country:US
Mailing Address - Phone:940-553-2140
Mailing Address - Fax:940-553-1739
Practice Address - Street 1:4103 WILBARGER ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3137
Practice Address - Country:US
Practice Address - Phone:940-553-2140
Practice Address - Fax:940-553-1739
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165574802Medicaid
TXE87143Medicare UPIN