Provider Demographics
NPI:1558330746
Name:SANDERS, VAUGHN G (OD)
Entity Type:Individual
Prefix:DR
First Name:VAUGHN
Middle Name:G
Last Name:SANDERS
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 1:1705 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-4814
Mailing Address - Country:US
Mailing Address - Phone:270-683-2121
Mailing Address - Fax:270-683-3167
Practice Address - Street 1:1705 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4814
Practice Address - Country:US
Practice Address - Phone:270-683-2121
Practice Address - Fax:270-683-3167
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY763DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77904019Medicaid
KY000000354055OtherANTHEM BCBS NUMBER
KY77007631Medicaid
KY77007631Medicaid
KY0001701Medicare ID - Type Unspecified
KY77904019Medicaid
KY000000354055OtherANTHEM BCBS NUMBER