Provider Demographics
NPI:1992900062
Name:OSBOURNE, AUDLEY LLOYD MARTIN (MD)
Entity type:Individual
Prefix:
First Name:AUDLEY
Middle Name:LLOYD MARTIN
Last Name:OSBOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:5065 STATE ROAD 7
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33449-4615
Practice Address - Country:US
Practice Address - Phone:561-432-0037
Practice Address - Fax:561-432-0066
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-224804208600000X
FLME113487208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14426OtherDIMENSION
FL14NN3OtherBCBS
FLP971629OtherOPTIMUM
FL1096529OtherWELLCARE
FL0363920OtherCIGNA
FL9155643OtherAETNA
FL362745OtherAVMED
FLP01604782OtherRR MEDICARE
FLP1035875OtherFREEDOM
FL362745OtherAVMED