Healthcare Provider Details

I. General information

NPI: 1083777460
Provider Name (Legal Business Name): TYLER VACHON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHERRY LN STE 116
MANTECA CA
95337-4398
US

IV. Provider business mailing address

250 CHERRY LN STE 116
MANTECA CA
95337-4398
US

V. Phone/Fax

Practice location:
  • Phone: 209-647-2184
  • Fax:
Mailing address:
  • Phone: 209-647-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA151542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: