Provider Demographics
NPI:1063514412
Name:WITT, VAUGHN P
Entity type:Individual
Prefix:
First Name:VAUGHN
Middle Name:P
Last Name:WITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 US HIGHWAY 77
Mailing Address - Street 2:STE B3
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4542
Mailing Address - Country:US
Mailing Address - Phone:361-241-9357
Mailing Address - Fax:361-241-4461
Practice Address - Street 1:4101 US HIGHWAY 77
Practice Address - Street 2:STE B3
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4542
Practice Address - Country:US
Practice Address - Phone:361-241-9357
Practice Address - Fax:361-241-4461
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02183TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093320201Medicaid
TX00E59CMedicare PIN
TX0659640001Medicare NSC
TX093320201Medicaid