Provider Demographics
NPI:1952402133
Name:CHARLES R. VAUGHN DO, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHARLES R. VAUGHN DO, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-848-8891
Mailing Address - Street 1:11625 FIRESTONE BLVD
Mailing Address - Street 2:6-305
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8810
Mailing Address - Country:US
Mailing Address - Phone:818-848-8891
Mailing Address - Fax:818-848-8892
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2424
Practice Address - Country:US
Practice Address - Phone:818-848-8891
Practice Address - Fax:818-848-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7510207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI01279Medicare UPIN
CAW20239Medicare PIN