Provider Demographics
NPI:1144216987
Name:VAUGHAN, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:11803 JEFFERSON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2565
Practice Address - Country:US
Practice Address - Phone:757-873-0360
Practice Address - Fax:757-873-0847
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101042292207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144216987Medicaid
VAF49680Medicare UPIN
VA018586R53Medicare PIN
VA1144216987Medicaid