Provider Demographics
NPI:1396754222
Name:VAUGHN, REBECCA YOUNGBLOOD (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:YOUNGBLOOD
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:148 BILL CARRUTH PKWY
Mailing Address - Street 2:SUITE 280
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3754
Mailing Address - Country:US
Mailing Address - Phone:678-363-3343
Mailing Address - Fax:678-363-3380
Practice Address - Street 1:148 BILL CARRUTH PKWY
Practice Address - Street 2:STE 280
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3754
Practice Address - Country:US
Practice Address - Phone:678-363-3343
Practice Address - Fax:678-363-3380
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033899207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE96922Medicare UPIN
GAGRP4885Medicare ID - Type Unspecified