Provider Demographics
NPI:1902840697
Name:VAUGHN, TRACI LYDRICKA (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYDRICKA
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NATCHITOCHES ST
Mailing Address - Street 2:APT 104
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-3161
Mailing Address - Country:US
Mailing Address - Phone:504-376-3500
Mailing Address - Fax:
Practice Address - Street 1:221 W HICKORY AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4551
Practice Address - Country:US
Practice Address - Phone:318-281-6111
Practice Address - Fax:318-281-4429
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023914207Y00000X
TXM3777207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8H8818OtherBLUE CROSS BLUE SHIELD
TX8J1015Medicare PIN
TXH97336Medicare UPIN
TX8H8818OtherBLUE CROSS BLUE SHIELD
TX8H8818OtherBLUE CROSS BLUE SHIELD
TX8G4711Medicare ID - Type Unspecified
TXH97336Medicare UPIN
TX8G4712Medicare ID - Type Unspecified