Provider Demographics
NPI:1043498520
Name:VAUGHAN, OLADIJI GBOLAHAN (MD)
Entity Type:Individual
Prefix:
First Name:OLADIJI
Middle Name:GBOLAHAN
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36351 N GANTZEL RD STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7033
Mailing Address - Country:US
Mailing Address - Phone:480-336-2815
Mailing Address - Fax:877-281-3385
Practice Address - Street 1:36351 N GANTZEL RD STE 127
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7033
Practice Address - Country:US
Practice Address - Phone:480-336-2815
Practice Address - Fax:877-281-3385
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40162208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ358032-01Medicaid
AZZ143377Medicare PIN
AZ358032-01Medicaid
AZZ143689Medicare PIN
AZ123935Medicare PIN