Healthcare Provider Details

I. General information

NPI: 1285655837
Provider Name (Legal Business Name): IAN CHARLES OSBORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

IV. Provider business mailing address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-8978
  • Fax:
Mailing address:
  • Phone: 505-841-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number90-92
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD015381E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: