Provider Demographics
NPI:1689623811
Name:VAUGHT, KEVIN ALTON (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALTON
Last Name:VAUGHT
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:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-1329
Mailing Address - Country:US
Mailing Address - Phone:573-339-1957
Mailing Address - Fax:573-339-9709
Practice Address - Street 1:1723 BROADWAY
Practice Address - Street 2:SUITE 410
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-339-1957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003008356207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG91935Medicare UPIN