Healthcare Provider Details

I. General information

NPI: 1497789572
Provider Name (Legal Business Name): DENNIS RYAN VAUGHN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NORTH STATE HIGHWAY 121
MT. ZION IL
62549
US

IV. Provider business mailing address

1640 NORTH STATE HIGHWAY 121
MT. ZION IL
62549
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-1922
  • Fax: 217-864-1953
Mailing address:
  • Phone: 217-864-1922
  • Fax: 217-864-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005005
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: