Provider Demographics
NPI:1710174263
Name:OSBORNE, FREDERICK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MICHAEL
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 1:768 MOUNTAIN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9707
Mailing Address - Country:US
Mailing Address - Phone:209-754-3521
Mailing Address - Fax:
Practice Address - Street 1:768 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9707
Practice Address - Country:US
Practice Address - Phone:209-754-3521
Practice Address - Fax:209-754-2682
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12852174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38809Medicare UPIN