Provider Demographics
NPI:1417904376
Name:ELEM-VAUGHN, DURENE M (DPM)
Entity type:Individual
Prefix:
First Name:DURENE
Middle Name:M
Last Name:ELEM-VAUGHN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:DURENE
Other - Middle Name:M
Other - Last Name:ELEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1111 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1802
Mailing Address - Country:US
Mailing Address - Phone:313-386-0000
Mailing Address - Fax:313-386-1597
Practice Address - Street 1:1111 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1802
Practice Address - Country:US
Practice Address - Phone:313-386-0000
Practice Address - Fax:313-386-1597
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001503213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858252150OtherBLUE CROSS BLUE SHIELD
MI2710766Medicaid
MI4858252150OtherBLUE CROSS BLUE SHIELD
MI2710766Medicaid
MI4460450001Medicare NSC