Healthcare Provider Details

I. General information

NPI: 1073607149
Provider Name (Legal Business Name): KEESHA D. VAUGHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEESHA BONETT

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7TH & CLAYTON STREET SUITE 400
WILMINGTON DE
19805-3165
US

IV. Provider business mailing address

P.O. BOX 191
ROCKLAND DE
19723-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-421-9700
  • Fax: 302-421-9743
Mailing address:
  • Phone: 302-651-4000
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101238247
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10008819
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC10008819
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC10008819
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: