Provider Demographics
NPI:1497771422
Name:OSBORNE, MARK ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13706 COUNTY ROAD 291
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-4844
Mailing Address - Country:US
Mailing Address - Phone:903-253-5295
Mailing Address - Fax:
Practice Address - Street 1:1121 E SE LOOP 323
Practice Address - Street 2:STE 102
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9660
Practice Address - Country:US
Practice Address - Phone:903-561-1071
Practice Address - Fax:903-561-6841
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146782101Medicaid
8D2794Medicare ID - Type Unspecified
TX146782101Medicaid