Provider Demographics
NPI:1982766127
Name:COLBURN, PAUL B (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:COLBURN
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 1:520 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1517
Mailing Address - Country:US
Mailing Address - Phone:307-532-2060
Mailing Address - Fax:307-532-5710
Practice Address - Street 1:3726 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4665
Practice Address - Country:US
Practice Address - Phone:308-635-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY193T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY4100004467OtherRR MEDICARE PROVIDER NUMB
WY103409000Medicaid
WY310523OtherBCBS WY PROVIDER NUMBER
WY103409000Medicaid
WYW305380Medicare PIN
WYU02992Medicare UPIN
WY0312350002Medicare NSC