Provider Demographics
NPI:1093224388
Name:VAUGHN, ROLAND
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 LAKE CARILLON DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1130
Mailing Address - Country:US
Mailing Address - Phone:303-717-4336
Mailing Address - Fax:
Practice Address - Street 1:970 LAKE CARILLON DR STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1130
Practice Address - Country:US
Practice Address - Phone:303-717-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36510Medicaid