Provider Demographics
NPI:1912598194
Name:VAUGHN, CHARLES JORDAN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JORDAN
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2998 OLD TAYLOR RD APT 1412
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5654
Mailing Address - Country:US
Mailing Address - Phone:256-466-1365
Mailing Address - Fax:
Practice Address - Street 1:1808 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4112
Practice Address - Country:US
Practice Address - Phone:662-513-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program