Provider Demographics
NPI:1003960634
Name:OSBORNE, JEFFREY SHANE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SHANE
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:J. SHANE
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3469 MORTH MAYO TRAIL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501
Mailing Address - Country:US
Mailing Address - Phone:606-437-7702
Mailing Address - Fax:606-437-2307
Practice Address - Street 1:3469 N. MAYO TRAIL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-437-7702
Practice Address - Fax:606-437-2307
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1230-DT152W00000X
KY1230- DT152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1003960634Medicaid
KY77012300Medicaid
KYU26619Medicare UPIN
KY77012300Medicaid