Provider Demographics
NPI:1477544096
Name:COBURN, EMERTH LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:EMERTH
Middle Name:LANCE
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 1:214-01 110TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429
Mailing Address - Country:US
Mailing Address - Phone:718-276-4482
Mailing Address - Fax:718-276-4783
Practice Address - Street 1:227-19 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413
Practice Address - Country:US
Practice Address - Phone:718-276-4482
Practice Address - Fax:718-276-4783
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617674Medicaid
NY01962AMedicare ID - Type Unspecified
NY01617674Medicaid