Provider Demographics
NPI:1164423745
Name:COBURN, ERNEST L JR (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:L
Last Name:COBURN
Suffix:JR
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 1:315 FALLS DR NW
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-8093
Mailing Address - Country:US
Mailing Address - Phone:276-739-7989
Mailing Address - Fax:
Practice Address - Street 1:315 FALLS DR NW
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8093
Practice Address - Country:US
Practice Address - Phone:276-739-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY198852085R0202X
VA01010232082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64096902Medicaid
A99914Medicare UPIN
VA300002737Medicare PIN