Provider Demographics
NPI:1184771834
Name:COBURN, GARY T (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:T
Last Name:COBURN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-0278
Mailing Address - Country:US
Mailing Address - Phone:765-569-2008
Mailing Address - Fax:765-569-2009
Practice Address - Street 1:725 N LINCOLN ROAD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872
Practice Address - Country:US
Practice Address - Phone:765-569-2008
Practice Address - Fax:765-569-2009
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000264646OtherANTHEM
IN200954600Medicaid
IN410046751OtherRAILROAD MEDICARE
IN000000264522OtherANTHEM PIN
INT69238Medicare UPIN
IN000000264522OtherANTHEM PIN