Provider Demographics
NPI:1821182973
Name:VAUGHAN, WINSTON CANUTE (MD)
Entity Type:Individual
Prefix:
First Name:WINSTON
Middle Name:CANUTE
Last Name:VAUGHAN
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 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3408
Mailing Address - Fax:916-233-4171
Practice Address - Street 1:3351 EL CAMINO REAL
Practice Address - Street 2:STE 200
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-3811
Practice Address - Country:US
Practice Address - Phone:650-399-4630
Practice Address - Fax:650-366-4930
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821182973Medicare PIN