Provider Demographics
NPI:1528412236
Name:OSBORN, NATHANIEL (DO)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:OSBORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EILEEN WAY
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5302
Mailing Address - Country:US
Mailing Address - Phone:516-795-3033
Mailing Address - Fax:516-590-7684
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 206
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:863-231-4450
Practice Address - Fax:863-231-4456
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17563207XS0114X, 207XS0114X
NY39000000X207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1528412236Medicaid