Provider Demographics
NPI:1023093937
Name:OSBORN, GERALD G (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:OSBORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 INDEPENDENCE LN
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-3073
Mailing Address - Country:US
Mailing Address - Phone:423-562-1705
Mailing Address - Fax:423-566-3718
Practice Address - Street 1:130 INDEPENDENCE LN
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766
Practice Address - Country:US
Practice Address - Phone:423-462-1705
Practice Address - Fax:423-566-3718
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030151482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000489Medicaid
TN1512315Medicaid
MO208810002Medicaid