Provider Demographics
NPI:1699153528
Name:VAUGHT, CAROLYN ROENA
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ROENA
Last Name:VAUGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:109 PHYSICIANS DR STE A
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2446
Practice Address - Country:US
Practice Address - Phone:864-797-9150
Practice Address - Fax:864-797-9155
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC210102207Q00000X
SC87020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid