Healthcare Provider Details

I. General information

NPI: 1578503942
Provider Name (Legal Business Name): ANITA VAUGHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 BIRCHVIEW PL
CLINTON MD
20735-4817
US

IV. Provider business mailing address

5711 BIRCHVIEW PL
CLINTON MD
20735-4817
US

V. Phone/Fax

Practice location:
  • Phone: 908-472-1127
  • Fax: 862-252-9399
Mailing address:
  • Phone: 908-472-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA41607
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number308186
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: