Provider Demographics
NPI:1790704849
Name:COBURN, GREGORY LYNN (OD)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LYNN
Last Name:COBURN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 E GAY STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3103
Mailing Address - Country:US
Mailing Address - Phone:614-224-2414
Mailing Address - Fax:614-224-5916
Practice Address - Street 1:4864 W BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1602
Practice Address - Country:US
Practice Address - Phone:614-878-7771
Practice Address - Fax:614-878-4000
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0727057Medicaid
OHCO0714344Medicare ID - Type Unspecified
OH0727057Medicaid