Provider Demographics
NPI:1417942582
Name:OSBORN, KYLE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:THOMAS
Last Name:OSBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:510 GEYSER RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3007
Mailing Address - Country:US
Mailing Address - Phone:518-289-2720
Mailing Address - Fax:518-886-5880
Practice Address - Street 1:701 SENECA ST STE 646C
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1351
Practice Address - Country:US
Practice Address - Phone:716-995-4450
Practice Address - Fax:844-206-7424
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-09-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY224542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02806384Medicaid
NY02806384Medicaid
NYRB2381Medicare PIN