Provider Demographics
NPI:1497789572
Name:VAUGHN, DENNIS RYAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:RYAN
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 NORTH STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:MT. ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549
Mailing Address - Country:US
Mailing Address - Phone:217-864-1922
Mailing Address - Fax:217-864-1953
Practice Address - Street 1:1640 NORTH STATE HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:MT. ZION
Practice Address - State:IL
Practice Address - Zip Code:62549
Practice Address - Country:US
Practice Address - Phone:217-864-1922
Practice Address - Fax:217-864-1953
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005005213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005005Medicaid
IL626190Medicare ID - Type Unspecified
IL016005005Medicaid