Basic Information
| Provider Information | |||||||||
| NPI: | 1386141083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | JORDAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 16TH ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432549 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 81 N MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016625701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 11420245-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MED-PHYS-LIC-112709 | MT | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.