Provider Demographics
NPI:1649355462
Name:OSBORN, JUSTIN E (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:E
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE STE 205
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6594
Practice Address - Country:US
Practice Address - Phone:503-513-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028916207Q00000X
ORMD176531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1649355462Medicaid
WA0231720OtherL&I
8318OtherINTERNAL ID-MOTOR VEHICLE ID
F25372Medicare UPIN
WA1649355462Medicaid