Provider Demographics
NPI:1861499600
Name:VAUGHAN, CLIFTON M (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:M
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 1:1717 E. BERT KOUNS
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5561
Mailing Address - Country:US
Mailing Address - Phone:318-212-3930
Mailing Address - Fax:318-212-3935
Practice Address - Street 1:1717 E. BERT KOUNS
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5561
Practice Address - Country:US
Practice Address - Phone:318-212-3930
Practice Address - Fax:318-212-3935
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1313670Medicaid
LA1313670Medicaid