Provider Demographics
NPI:1073696845
Name:OSORIO, RUBEN (MD)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:OSORIO
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 1:399 E HIGHLAND AVE STE 319
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3858
Mailing Address - Country:US
Mailing Address - Phone:909-881-7200
Mailing Address - Fax:909-881-7289
Practice Address - Street 1:399 E HIGHLAND AVE STE 319
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3858
Practice Address - Country:US
Practice Address - Phone:909-881-7200
Practice Address - Fax:909-881-7289
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG081620208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G816200Medicaid
CA00G816202Medicare PIN
CA00G816200Medicaid
CA00G816201Medicare PIN