Provider Demographics
NPI:1699767293
Name:VAUGHN, GLEN E (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:E
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:PO BOX 633390
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3390
Mailing Address - Country:US
Mailing Address - Phone:800-594-1876
Mailing Address - Fax:
Practice Address - Street 1:2801 BAY PARK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4920
Practice Address - Country:US
Practice Address - Phone:419-690-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053859207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000246976OtherANTHEM
MI4488340Medicaid
OH000000550256OtherANTHEM
OH0634497Medicaid
MIMI1174010Medicare PIN
OHP00472621Medicare PIN
OHVA4224821Medicare PIN
OH000000246976OtherANTHEM
930121177Medicare ID - Type UnspecifiedRAILROAD
E78474Medicare UPIN
OHP00733200Medicare PIN