Provider Demographics
NPI:1669660213
Name:LAUREN JOHNSON OSULLIVAN
Entity Type:Organization
Organization Name:LAUREN JOHNSON OSULLIVAN
Other - Org Name:LAUREN O'SULLIVAN DO LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:O'SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-389-0450
Mailing Address - Street 1:1102 NE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4533
Mailing Address - Country:US
Mailing Address - Phone:541-389-0450
Mailing Address - Fax:541-389-9567
Practice Address - Street 1:1102 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4533
Practice Address - Country:US
Practice Address - Phone:541-389-0450
Practice Address - Fax:541-389-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO26683207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136055Medicare PIN