Provider Demographics
NPI:1174656870
Name:OSBORNE, KEVIN D (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 S PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2381
Mailing Address - Country:US
Mailing Address - Phone:509-764-7338
Mailing Address - Fax:509-764-7878
Practice Address - Street 1:215 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1717
Practice Address - Country:US
Practice Address - Phone:509-764-7338
Practice Address - Fax:509-764-7878
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031243Medicaid
WA2031243Medicaid
WAG8857190Medicare PIN
WAU86510Medicare UPIN