Provider Demographics
NPI:1437286747
Name:COBURN, VINCENT HARLON (OD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:HARLON
Last Name:COBURN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812B N ONE MILE RD
Mailing Address - Street 2:PO BOX 534
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1034
Mailing Address - Country:US
Mailing Address - Phone:573-624-8829
Mailing Address - Fax:573-624-3636
Practice Address - Street 1:812B N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1034
Practice Address - Country:US
Practice Address - Phone:573-624-8829
Practice Address - Fax:573-624-3636
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO311660906Medicaid
MO311660906Medicaid
MO7342Medicare ID - Type Unspecified