Healthcare Provider Details

I. General information

NPI: 1043498520
Provider Name (Legal Business Name): OLADIJI GBOLAHAN VAUGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36351 N GANTZEL RD STE 127
SAN TAN VALLEY AZ
85140-7033
US

IV. Provider business mailing address

36351 N GANTZEL RD STE 127
SAN TAN VALLEY AZ
85140-7033
US

V. Phone/Fax

Practice location:
  • Phone: 480-336-2815
  • Fax: 877-281-3385
Mailing address:
  • Phone: 480-336-2815
  • Fax: 877-281-3385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40162
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number40162
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: