Healthcare Provider Details

I. General information

NPI: 1457305104
Provider Name (Legal Business Name): JOEL FULLER VAUGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

2200 SANDPIPER RD
VIRGINIA BEACH VA
23456-4620
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone: 843-556-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23927
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23927
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: