Provider Demographics
NPI:1780666537
Name:VAUGHN, RICHARD SIDNEY (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SIDNEY
Last Name:VAUGHN
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 1:401 MOYE BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:384 MARINERS DR
Practice Address - Street 2:
Practice Address - City:ROPER
Practice Address - State:NC
Practice Address - Zip Code:27970-9014
Practice Address - Country:US
Practice Address - Phone:309-531-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20691207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC86905Medicare UPIN