Provider Demographics
NPI:1073503223
Name:VAUGHAN, AMY A II (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:VAUGHAN
Suffix:II
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:A
Other - Last Name:KEATON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:6007 US ROUTE 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 ROUTE 60 E
Practice Address - Street 2:SUITE 130
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1042
Practice Address - Country:US
Practice Address - Phone:304-733-3333
Practice Address - Fax:304-733-3666
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18579207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0070108000Medicaid
G31106Medicare UPIN
WV0806282Medicare ID - Type Unspecified
WV0070108000Medicaid