Provider Demographics
NPI:1558464537
Name:COLBURN, REBECCA J (OD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:J
Last Name:COLBURN
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:10260 JORDAN RIVER DR SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9189
Mailing Address - Country:US
Mailing Address - Phone:616-891-7280
Mailing Address - Fax:
Practice Address - Street 1:5859 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6905
Practice Address - Country:US
Practice Address - Phone:616-949-5125
Practice Address - Fax:616-949-5843
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901003964152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M77550Medicare UPIN