1922017235 NPI number — THOMAS KEITH VAUGHAN MD

Table of content: THOMAS KEITH VAUGHAN MD (NPI 1922017235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922017235 NPI number — THOMAS KEITH VAUGHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHAN
Provider First Name:
THOMAS
Provider Middle Name:
KEITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922017235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
929 E MAIN AVE
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-3116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-841-2453
Provider Business Mailing Address Fax Number:
253-840-5519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
929 E MAIN AVE
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-2453
Provider Business Practice Location Address Fax Number:
253-840-5519
Provider Enumeration Date:
08/05/2006

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: 207N00000X , with the licence number:  MD00044588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7095656 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0236932 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 53030 GROUP . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00642708 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8422511 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS6844 GROUP . This is a "RR MED" identifier . This identifiers is of the category "OTHER".




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