Provider Demographics
NPI:1871729277
Name:COBURN, AMY ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:COBURN
Suffix:
Gender:F
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:HIGHLAND CLINIC, APMC
Mailing Address - Street 2:1400 E. BERT KOUNS, SUITE #103
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-222-8402
Mailing Address - Fax:318-222-4556
Practice Address - Street 1:HIGHLAND CLINIC, APMC
Practice Address - Street 2:1400 E. BERT KOUNS, SUITE #103
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-222-8402
Practice Address - Fax:318-222-4556
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1574-607T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185546722Medicaid
LA1888982Medicaid
LA1888982Medicaid