Provider Demographics
NPI:1780649988
Name:VAUGHAN, JEFFERSON ROGER SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:ROGER
Last Name:VAUGHAN
Suffix:SR
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 7532
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-7532
Mailing Address - Country:US
Mailing Address - Phone:561-741-5695
Mailing Address - Fax:561-741-5697
Practice Address - Street 1:1002 S OLD DIXIE HWY
Practice Address - Street 2:STE 203
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7202
Practice Address - Country:US
Practice Address - Phone:561-741-5695
Practice Address - Fax:561-741-5697
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055039208600000X
AL00026990208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26751Medicare ID - Type Unspecified
FLG03497Medicare UPIN