Provider Demographics
NPI:1225196421
Name:OSBORNE, MICHAEL VERNON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VERNON
Last Name:OSBORNE
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 1:5440 SW WESTGATE DR
Mailing Address - Street 2:220
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2420
Mailing Address - Country:US
Mailing Address - Phone:503-292-7577
Mailing Address - Fax:503-292-7971
Practice Address - Street 1:5440 SW WESTGATE DR
Practice Address - Street 2:220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2420
Practice Address - Country:US
Practice Address - Phone:503-292-7577
Practice Address - Fax:503-292-7971
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17362207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR072041Medicaid
OR072041Medicaid
ORF71599Medicare UPIN