Provider Demographics
NPI:1316168032
Name:JOSEPH K VAUGHAN, JR, MD, PA
Entity type:Organization
Organization Name:JOSEPH K VAUGHAN, JR, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAUGHAN, JR. MD, PA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-534-4700
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1169
Mailing Address - Country:US
Mailing Address - Phone:903-534-4700
Mailing Address - Fax:903-534-4709
Practice Address - Street 1:921 SHILOH RD
Practice Address - Street 2:SUITE C200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1431
Practice Address - Country:US
Practice Address - Phone:903-534-4700
Practice Address - Fax:903-534-4709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH37289Medicare UPIN
TX00397UMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER