Healthcare Provider Details

I. General information

NPI: 1033164231
Provider Name (Legal Business Name): JESSICA M. VAUGHT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W COLUMBIA ST
ORLANDO FL
32806-1133
US

IV. Provider business mailing address

21 COLUMBIA ST
ORLANDO FL
32806-1133
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5560
  • Fax: 321-841-2442
Mailing address:
  • Phone: 321-841-5560
  • Fax: 321-841-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD035459
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101237916
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0062938
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME97643
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME97643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: