Provider Demographics
NPI:1447436027
Name:KENNETH D. OSORIO, M.D., PLLC
Entity type:Organization
Organization Name:KENNETH D. OSORIO, M.D., PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:OSORIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-844-8346
Mailing Address - Street 1:3514 N POWER RD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2903
Mailing Address - Country:US
Mailing Address - Phone:480-844-8346
Mailing Address - Fax:480-889-6997
Practice Address - Street 1:3514 N POWER RD
Practice Address - Street 2:SUITE 118
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2903
Practice Address - Country:US
Practice Address - Phone:480-844-8346
Practice Address - Fax:480-889-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ75946Medicare PIN