Basic Information
| Provider Information | |||||||||
| NPI: | 1003960634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OSBORNE | ||||||||
| OtherFirstName: | J. SHANE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3469 MORTH MAYO TRAIL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3469 N. MAYO TRAIL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1230-DT | KY | Y | Eye and Vision Services Providers | Optometrist | 152WL0500X | 1230- DT | KY | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1003960634 | 05 | KY | MEDICAID | 77012300 | 05 | KY | MEDICAID |