Provider Demographics
NPI:1386687002
Name:GRAVES, VAUGHAN C (MD)
Entity Type:Individual
Prefix:
First Name:VAUGHAN
Middle Name:C
Last Name:GRAVES
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 1:601 WALNUT ST
Mailing Address - Street 2:SUITE L90
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3304
Mailing Address - Country:US
Mailing Address - Phone:215-238-1622
Mailing Address - Fax:215-238-1944
Practice Address - Street 1:601 WALNUT ST
Practice Address - Street 2:SUITE L90
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19106-3304
Practice Address - Country:US
Practice Address - Phone:215-238-1622
Practice Address - Fax:215-238-1944
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028158E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009410580004Medicaid
B33495Medicare UPIN
024209Medicare ID - Type Unspecified