Provider Demographics
NPI:1558559468
Name:DOUGLAS M. VAUGHN, D.O., P.C.
Entity Type:Organization
Organization Name:DOUGLAS M. VAUGHN, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-749-5714
Mailing Address - Street 1:4629 S HARVARD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2948
Mailing Address - Country:US
Mailing Address - Phone:918-749-5714
Mailing Address - Fax:918-749-5826
Practice Address - Street 1:4629 S HARVARD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2948
Practice Address - Country:US
Practice Address - Phone:918-749-5714
Practice Address - Fax:918-749-5826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1943261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100095460AMedicaid
OK100095460AMedicaid