Healthcare Provider Details

I. General information

NPI: 1386141083
Provider Name (Legal Business Name): JORDAN VAUGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SUNNYVIEW LN
KALISPELL MT
59901-3129
US

IV. Provider business mailing address

355 BLUE SPRUCE LN
KALISPELL MT
59901-6830
US

V. Phone/Fax

Practice location:
  • Phone: 406-751-5310
  • Fax: 406-751-3068
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMED-PHYS-LIC-112709
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: