Healthcare Provider Details

I. General information

NPI: 1750762167
Provider Name (Legal Business Name): ANDREW DOUGLAS VAUGHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DRIVE FAMILY MEDICINE CENTER
COLUMBIA SC
29203
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6113
  • Fax: 803-434-8478
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38406
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL38406
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: