Healthcare Provider Details

I. General information

NPI: 1477544096
Provider Name (Legal Business Name): EMERTH LANCE COBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21401 110TH AVE
QUEENS VILLAGE NY
11429-1906
US

IV. Provider business mailing address

214-01 110TH AVENUE
QUEENS VILLAGE NY
11429
US

V. Phone/Fax

Practice location:
  • Phone: 929-615-6447
  • Fax: 718-276-4783
Mailing address:
  • Phone: 718-276-4482
  • Fax: 718-276-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number198832
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number198832
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: