Provider Demographics
NPI:1407941743
Name:OSBOURNE, ABE GOLDSWORTHY (DPM)
Entity type:Individual
Prefix:
First Name:ABE
Middle Name:GOLDSWORTHY
Last Name:OSBOURNE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23780 HALBURTON RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7603
Mailing Address - Country:US
Mailing Address - Phone:216-765-1559
Mailing Address - Fax:216-765-1559
Practice Address - Street 1:4415 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3759
Practice Address - Country:US
Practice Address - Phone:216-231-5612
Practice Address - Fax:216-721-5534
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002695213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCH5179OtherRR MEDICARE GROUP
OH2740458Medicaid
OHP00435156OtherRR MEDICARE #
OH2740458Medicaid
OHV10369Medicare UPIN
OH4310000001Medicare NSC
OH9312431Medicare PIN