Provider Demographics
NPI:1073591004
Name:VAUGHAN, MICHAEL DERALD (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DERALD
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8554 KAPP DR
Mailing Address - Street 2:BOX 102
Mailing Address - City:PEOSTA
Mailing Address - State:IA
Mailing Address - Zip Code:52068-9759
Mailing Address - Country:US
Mailing Address - Phone:563-557-1212
Mailing Address - Fax:
Practice Address - Street 1:8554 KAPP DR
Practice Address - Street 2:BOX 102
Practice Address - City:PEOSTA
Practice Address - State:IA
Practice Address - Zip Code:52068-9759
Practice Address - Country:US
Practice Address - Phone:563-557-1212
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA44943Medicare ID - Type Unspecified