Healthcare Provider Details

I. General information

NPI: 1023093937
Provider Name (Legal Business Name): GERALD G OSBORN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 INDEPENDENCE LN
LA FOLLETTE TN
37766
US

IV. Provider business mailing address

130 INDEPENDENCE LN
LA FOLLETTE TN
37766-3073
US

V. Phone/Fax

Practice location:
  • Phone: 423-462-1705
  • Fax: 423-566-3718
Mailing address:
  • Phone: 423-562-1705
  • Fax: 423-566-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2003015148
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: