Provider Demographics
NPI:1124065479
Name:VAUGHAN, SUSAN A (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 STATELINE RD
Mailing Address - Street 2:
Mailing Address - City:COLCORD
Mailing Address - State:OK
Mailing Address - Zip Code:74338-1348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 STATELINE RD
Practice Address - Street 2:
Practice Address - City:COLCORD
Practice Address - State:OK
Practice Address - Zip Code:74338-1348
Practice Address - Country:US
Practice Address - Phone:918-422-5811
Practice Address - Fax:918-422-5709
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2026152W00000X
AR2405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764550AMedicaid
AR117841722Medicaid
OK6928350001OtherCIGNA GOVERNEMENT SERVICES
OKU11722Medicare UPIN
OK235631901Medicare PIN
OK6928350001OtherCIGNA GOVERNEMENT SERVICES