Provider Demographics
NPI:1154411908
Name:AMY A VAUGHAN DERMATOLOGY PLLC
Entity type:Organization
Organization Name:AMY A VAUGHAN DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-733-3333
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:6007 US RT 60 E SUITE 130
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504
Mailing Address - Country:US
Mailing Address - Phone:304-733-3333
Mailing Address - Fax:304-733-3666
Practice Address - Street 1:6007 US RT 60 EAST
Practice Address - Street 2:SUITE 130
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-733-3333
Practice Address - Fax:304-733-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18579207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31106Medicare UPIN
WV0806281Medicare ID - Type Unspecified