Provider Demographics
NPI:1821083023
Name:OSBORNE, JAY RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:RICHARD
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 1:10850 MAHONING AVE
Mailing Address - Street 2:P. O. BOX 487
Mailing Address - City:NORTH JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:44451-8705
Mailing Address - Country:US
Mailing Address - Phone:330-538-2490
Mailing Address - Fax:330-538-2575
Practice Address - Street 1:10850 MAHONING AVE
Practice Address - Street 2:BOX 487
Practice Address - City:NORTH JACKSON
Practice Address - State:OH
Practice Address - Zip Code:44451-8705
Practice Address - Country:US
Practice Address - Phone:330-538-2490
Practice Address - Fax:330-538-2575
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-8686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820491Medicaid
OH0651313Medicare ID - Type Unspecified
OHE91989Medicare UPIN