Basic Information
| Provider Information | |||||||||
| NPI: | 1336342021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEVEN G. VAUGHAN MD, PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29845 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727634 | ||||||||
| FaxNumber: | 5208727969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 W SAINT MARYS RD | ||||||||
| Address2: | #115 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208822172 | ||||||||
| FaxNumber: | 5206239125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BEAUVAIS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5208727634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29930 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 692740 | 05 | AZ | MEDICAID |