Provider Demographics
NPI:1760674956
Name:COBURN, BILLY BOB (DC)
Entity Type:Individual
Prefix:DR
First Name:BILLY
Middle Name:BOB
Last Name:COBURN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 THIS WAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5128
Mailing Address - Country:US
Mailing Address - Phone:979-299-1898
Mailing Address - Fax:979-299-3282
Practice Address - Street 1:512 THIS WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5128
Practice Address - Country:US
Practice Address - Phone:979-299-1898
Practice Address - Fax:979-299-3282
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9981111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV05293Medicare UPIN
TX8F0133Medicare PIN