Provider Demographics
NPI:1629044334
Name:OSBORN, JOHN CLARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARK
Last Name:OSBORN
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 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-540-7730
Mailing Address - Fax:918-540-7797
Practice Address - Street 1:310 2ND AVE SW
Practice Address - Street 2:107-B
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6743
Practice Address - Country:US
Practice Address - Phone:918-540-7730
Practice Address - Fax:918-540-7797
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15646207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200468380OMedicaid
MO500156005Medicaid
MO207709718Medicaid
OK100096540AMedicaid
800522468Medicare PIN
MO500156005Medicaid
MO207709718Medicaid
248526902Medicare PIN
P00254791Medicare PIN
D35099Medicare UPIN
OK100710600FMedicaid
OKOKAAA3239Medicare PIN