Healthcare Provider Details

I. General information

NPI: 1730402850
Provider Name (Legal Business Name): MR. PHILIP C VAUGHN II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3134
US

IV. Provider business mailing address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3134
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-5654
  • Fax:
Mailing address:
  • Phone: 619-692-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRHT60421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: