Provider Demographics
NPI:1578753612
Name:VAUGHN, JEFFREY M (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 E THOMAS RD
Mailing Address - Street 2:BUILDING 2108, SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-512-8030
Mailing Address - Fax:602-512-8161
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-3033
Practice Address - Fax:602-241-0292
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231349207X00000X
AZ5037207XX0005X, 207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ373223Medicaid