1568483014 NPI number — DR. ORIE THOMAS VAUGHN DPM

Table of content: DR. ORIE THOMAS VAUGHN DPM (NPI 1568483014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568483014 NPI number — DR. ORIE THOMAS VAUGHN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHN
Provider First Name:
ORIE
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAUGHN
Provider Other First Name:
O
Provider Other Middle Name:
THOMAS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568483014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91379
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90009-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-419-1060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 N LA BREA AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-1752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-419-1060
Provider Business Practice Location Address Fax Number:
310-412-3079
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  E2187 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000E21870 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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