MEDICARE: MR. GREGORY LYNN COBURN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3597	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790704849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY LYNN COBURN OD

Provider Business Mailing Address
First Line	:	81 E GAY STREET
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-3103
Country	:	US
Telephone Number	:	614-224-2414
Fax Number	:	614-224-5916

Provider Business Practice Location Address
First Line	:	4864 W BROAD STREET
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1602
Country	:	US
Telephone Number	:	614-878-7771
Fax Number	:	614-878-4000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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