Provider Demographics
NPI:1467666248
Name:OSORIO, MARK WESLEY (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WESLEY
Last Name:OSORIO
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 1:5893 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-5032
Mailing Address - Country:US
Mailing Address - Phone:734-459-1297
Mailing Address - Fax:
Practice Address - Street 1:29500 7 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1910
Practice Address - Country:US
Practice Address - Phone:248-477-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9000H11345-0OtherBSBC OF MI.
MA0 P20330Medicare ID - Type UnspecifiedXEYES, INC
MIP20330001Medicare ID - Type UnspecifiedOPTOMETRIST
MIU39568Medicare UPIN