Provider Demographics
NPI:1679564611
Name:LANE, CLINTON VI (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:LANE
Suffix:VI
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 1:377 PERKINS ST
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6826
Mailing Address - Country:US
Mailing Address - Phone:707-938-2345
Mailing Address - Fax:707-938-5722
Practice Address - Street 1:377 PERKINS ST
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6826
Practice Address - Country:US
Practice Address - Phone:707-938-2345
Practice Address - Fax:707-938-5722
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23570Medicare UPIN
CA00A235010Medicare ID - Type UnspecifiedMEDICARE/MEDICAL NUMBER