Provider Demographics
NPI:1831171024
Name:COBURN, BRY HENRY (MD)
Entity type:Individual
Prefix:MR
First Name:BRY
Middle Name:HENRY
Last Name:COBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:833 SAINT VINCENTS DR
Mailing Address - Street 2:STE 207 POB 3
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1606
Mailing Address - Country:US
Mailing Address - Phone:205-933-1380
Mailing Address - Fax:205-930-9222
Practice Address - Street 1:833 SAINT VINCENTS DR
Practice Address - Street 2:STE 207 POB 3
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1606
Practice Address - Country:US
Practice Address - Phone:205-933-1380
Practice Address - Fax:205-930-9222
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL5794207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1831171024Medicaid
AL1831171024Medicare NSC
1831171024Medicare UPIN
AL1831171024Medicare UPIN
AL1831171024Medicaid
AL1831171024Medicare Oscar/Certification
1831171024Medicare PIN