Healthcare Provider Details

I. General information

NPI: 1780625905
Provider Name (Legal Business Name): CHARLES RAYMOND VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 TEXAS ST
PECOS TX
79772-7338
US

IV. Provider business mailing address

2323 TEXAS ST
PECOS TX
79772-7338
US

V. Phone/Fax

Practice location:
  • Phone: 432-447-3551
  • Fax: 432-447-5434
Mailing address:
  • Phone: 432-447-3551
  • Fax: 432-447-5434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberN6084
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: