Healthcare Provider Details

I. General information

NPI: 1154411908
Provider Name (Legal Business Name): AMY A VAUGHAN DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 US RT 60 EAST SUITE 130
BARBOURSVILLE WV
25504
US

IV. Provider business mailing address

PO BOX 937 6007 US RT 60 E SUITE 130
BARBOURSVILLE WV
25504
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-3333
  • Fax: 304-733-3666
Mailing address:
  • Phone: 304-733-3333
  • Fax: 304-733-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number18579
License Number StateWV

VIII. Authorized Official

Name: AMY A VAUGHAN
Title or Position: PHYSICIAN PRESIDENT
Credential: MD
Phone: 304-733-3333