Provider Demographics
NPI:1073562237
Name:COBURN, THOMAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:COBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4795 LARIMER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9021
Mailing Address - Country:US
Mailing Address - Phone:970-669-8881
Mailing Address - Fax:970-669-4200
Practice Address - Street 1:214 S. 4TH STREET
Practice Address - Street 2:
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-0399
Practice Address - Country:US
Practice Address - Phone:970-887-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01360577Medicaid
COA498-8Medicare ID - Type Unspecified
COF37697Medicare UPIN