Healthcare Provider Details

I. General information

NPI: 1972546604
Provider Name (Legal Business Name): GARY JESSE VAUGHN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301
US

IV. Provider business mailing address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM9151
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberM-9151
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: