Provider Demographics
NPI:1306929864
Name:VAUGHN, LARRY ALAN (MD)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALAN
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:770-838-8929
Mailing Address - Fax:770-838-8930
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-838-8929
Practice Address - Fax:770-838-8930
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029812207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000374195EMedicaid
GA11SCDKKMedicare ID - Type Unspecified