Healthcare Provider Details

I. General information

NPI: 1124065479
Provider Name (Legal Business Name): SUSAN A VAUGHAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 STATELINE RD
COLCORD OK
74338-1348
US

IV. Provider business mailing address

820 STATELINE RD
COLCORD OK
74338-1348
US

V. Phone/Fax

Practice location:
  • Phone: 918-422-5811
  • Fax: 918-422-5709
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2026
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2405
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: