Healthcare Provider Details

I. General information

NPI: 1528061132
Provider Name (Legal Business Name): DUSTAN C OSBORN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date: 03/17/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1201 BISHOP RD
CHEHALIS WA
98532-8711
US

IV. Provider business mailing address

1201 BISHOP RD
CHEHALIS WA
98532-8711
US

V. Phone/Fax

Practice location:
  • Phone: 360-345-1381
  • Fax: 360-345-1382
Mailing address:
  • Phone: 360-345-1381
  • Fax: 360-345-1382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00021486
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMED-PHYS-LIC-109470
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD00021486
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: