Provider Demographics
NPI:1922017235
Name:VAUGHAN, THOMAS KEITH (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:KEITH
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 E MAIN AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3116
Mailing Address - Country:US
Mailing Address - Phone:253-841-2453
Mailing Address - Fax:253-840-5519
Practice Address - Street 1:929 E MAIN AVE
Practice Address - Street 2:STE 210
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3116
Practice Address - Country:US
Practice Address - Phone:253-841-2453
Practice Address - Fax:253-840-5519
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044588207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7095656Medicaid
WA0236932OtherL&I
WA53030 GROUPOtherL&I
P00642708OtherRR MEDICARE
WA8422511Medicaid
CS6844 GROUPOtherRR MED
WA8422511Medicaid