Provider Demographics
NPI:1619224722
Name:VAUGHT, JAMES DYLAN (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DYLAN
Last Name:VAUGHT
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 1:1406 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3567
Mailing Address - Country:US
Mailing Address - Phone:843-488-4147
Mailing Address - Fax:843-488-0141
Practice Address - Street 1:1406 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3567
Practice Address - Country:US
Practice Address - Phone:843-488-4147
Practice Address - Fax:843-488-0141
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD17248Medicaid