Provider Demographics
NPI:1568904738
Name:COGBURN, PIERCE
Entity Type:Individual
Prefix:
First Name:PIERCE
Middle Name:
Last Name:COGBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 OLD FORGE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2173
Mailing Address - Country:US
Mailing Address - Phone:847-508-0755
Mailing Address - Fax:
Practice Address - Street 1:3985 OLD FORGE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2173
Practice Address - Country:US
Practice Address - Phone:847-508-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman