Provider Demographics
NPI:1992737233
Name:COBURN, BRUCE DANIEL (BS DC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:DANIEL
Last Name:COBURN
Suffix:
Gender:M
Credentials:BS DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-5735
Mailing Address - Country:US
Mailing Address - Phone:979-849-8551
Mailing Address - Fax:888-620-0705
Practice Address - Street 1:801 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-5735
Practice Address - Country:US
Practice Address - Phone:979-849-8551
Practice Address - Fax:888-620-0705
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC8798111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U85610Medicare UPIN
TX609564Medicare ID - Type Unspecified