Provider Demographics
NPI:1619973047
Name:OSTERHUS, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:OSTERHUS
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 1:5 SHERIDAN SQ
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7390
Mailing Address - Country:US
Mailing Address - Phone:423-246-8155
Mailing Address - Fax:423-246-8658
Practice Address - Street 1:5 SHERIDAN SQ
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7390
Practice Address - Country:US
Practice Address - Phone:423-246-8155
Practice Address - Fax:423-246-8658
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38788207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010138418Medicaid
TN3896008Medicaid
KY7100013330Medicaid
VA010138418Medicaid
KY7100013330Medicaid
TNI16491Medicare UPIN