Healthcare Provider Details

I. General information

NPI: 1235137647
Provider Name (Legal Business Name): KENNETH OSGOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8213 POINT VIEW CT
LAS VEGAS NV
89128-7443
US

IV. Provider business mailing address

8213 POINT VIEW CT
LAS VEGAS NV
89128-7443
US

V. Phone/Fax

Practice location:
  • Phone: 702-228-2569
  • Fax:
Mailing address:
  • Phone: 702-228-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7336
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC31623
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73-177
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: