Provider Demographics
NPI:1568483014
Name:VAUGHN, ORIE THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:ORIE
Middle Name:THOMAS
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:O
Other - Middle Name:THOMAS
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 91379
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-1379
Mailing Address - Country:US
Mailing Address - Phone:310-419-1060
Mailing Address - Fax:
Practice Address - Street 1:111 N LA BREA AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1752
Practice Address - Country:US
Practice Address - Phone:310-419-1060
Practice Address - Fax:310-412-3079
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2187213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21870Medicaid
CAAV7602116OtherDEA #
CAAV7602116OtherDEA #
CA000E21870Medicaid