Provider Demographics
NPI:1477696169
Name:VAUGHAN, WILLIAM H (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1505
Mailing Address - Country:US
Mailing Address - Phone:781-593-2056
Mailing Address - Fax:781-592-6499
Practice Address - Street 1:32 STATE ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1505
Practice Address - Country:US
Practice Address - Phone:781-593-2056
Practice Address - Fax:781-592-6499
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0331295Medicaid
MAT59242Medicare UPIN
MA0331295Medicaid
0475620001Medicare NSC