Healthcare Provider Details

I. General information

NPI: 1366763062
Provider Name (Legal Business Name): ANA VAUGHAN-MALLOY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANA VAUGHAN

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone: 617-355-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberMT209054
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number47885
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number274930
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: