Provider Demographics
NPI:1659317733
Name:OSBORNE, VIC A (MD)
Entity Type:Individual
Prefix:
First Name:VIC
Middle Name:A
Last Name:OSBORNE
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 1:1050 LAKES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2924
Mailing Address - Country:US
Mailing Address - Phone:626-918-6655
Mailing Address - Fax:
Practice Address - Street 1:1135 S SUNSET AVE STE 200
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-918-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45453207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11816Medicare UPIN
WA45453BMedicare ID - Type Unspecified