Basic Information
| Provider Information | |||||||||
| NPI: | 1932337052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREY | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | MIKAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854934578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 726 N ACADIA RD. | ||||||||
| Address2: | STE 3300 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933080 | ||||||||
| FaxNumber: | 9854933081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | MD.205457 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 1894192 | 05 | LA | MEDICAID |