Healthcare Provider Details

I. General information

NPI: 1740238104
Provider Name (Legal Business Name): KEITH KENNETH VAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 BROADWAY UNIT 120
SONOMA CA
95476-2402
US

IV. Provider business mailing address

617 BROADWAY UNIT 120
SONOMA CA
95476-2402
US

V. Phone/Fax

Practice location:
  • Phone: 619-777-8321
  • Fax: 858-345-5019
Mailing address:
  • Phone: 619-750-8289
  • Fax: 858-345-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA87297
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA87297
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberA87297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: