=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588163729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL DALE OSBORNE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 RIVER OAKS RD
-----------------------------------------------------
City | HALF MOON BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-477-3269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 RIVER OAKS RD.
-----------------------------------------------------
City | HALF MOON BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-477-3269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | C31131
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------