Provider Demographics
NPI:1003027822
Name:OSBORN, JOHN JAY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
Last Name:OSBORN
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 1:139 CLEARVIEW CT
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6192
Mailing Address - Country:US
Mailing Address - Phone:808-349-5213
Mailing Address - Fax:
Practice Address - Street 1:CARL R. DARNELL ARMY MEDICAL CENTER
Practice Address - Street 2:36065 SANTA FE AVE
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-553-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC200332086S0129X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2021Medicaid
SCF33876Medicare UPIN