Provider Demographics
NPI:1467443804
Name:VAUGHAN, JERRY A (OD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W. 39TH ST.
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845
Mailing Address - Country:US
Mailing Address - Phone:308-865-2760
Mailing Address - Fax:308-865-2769
Practice Address - Street 1:411 W. 39TH ST.
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845
Practice Address - Country:US
Practice Address - Phone:308-865-2760
Practice Address - Fax:308-865-2769
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6721OtherBLUE CROSS BLUE SHIELD NE
NE10025593300Medicaid
NE47077269013Medicaid
NE410016528OtherRAILROAD INDIV PROVIDER #
NET40289Medicare UPIN
NE263642VAMedicare ID - Type Unspecified
NE6721OtherBLUE CROSS BLUE SHIELD NE