Healthcare Provider Details

I. General information

NPI: 1174713127
Provider Name (Legal Business Name): HOUMAN VAGHEFI MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-2888
  • Fax: 574-364-2480
Mailing address:
  • Phone: 574-364-2888
  • Fax: 574-364-2480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01069614A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: