Healthcare Provider Details

I. General information

NPI: 1114929718
Provider Name (Legal Business Name): JOHN ANDREW OSBORNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 WILLIAM D TATE AVE STE 850
GRAPEVINE TX
76051-8757
US

IV. Provider business mailing address

3801 WILLIAM D TATE AVE STE 850
GRAPEVINE TX
76051-8757
US

V. Phone/Fax

Practice location:
  • Phone: 817-310-3070
  • Fax:
Mailing address:
  • Phone: 817-310-3070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberK4180
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberK4180
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: