Basic Information
| Provider Information | |||||||||
| NPI: | 1366429722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1301 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764504240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405215412 | ||||||||
| FaxNumber: | 9405215289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764504240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208822172 | ||||||||
| FaxNumber: | 9405215289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29930 | AZ | Y | Other Service Providers | Specialist |
No ID Information.