Provider Demographics
NPI:1972582534
Name:VAUGHAN, GRANVILLE LEROY III (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANVILLE
Middle Name:LEROY
Last Name:VAUGHAN
Suffix:III
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 1018
Mailing Address - Street 2:2225 HIGHWAY 110 WEST
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-1018
Mailing Address - Country:US
Mailing Address - Phone:501-362-0048
Mailing Address - Fax:501-362-8815
Practice Address - Street 1:2225 HIGHWAY 110 W
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-3404
Practice Address - Country:US
Practice Address - Phone:501-326-0048
Practice Address - Fax:501-362-8815
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149045002Medicaid
AR51311OtherMEDICARE INDIVIDUAL NUMBER
AR149045002Medicaid