Healthcare Provider Details

I. General information

NPI: 1598889420
Provider Name (Legal Business Name): MICHAEL ROY VAUGHN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

712 CUMBERLAND CIR NE
ATLANTA GA
30306-3204
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 404-874-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number022660
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: