Healthcare Provider Details

I. General information

NPI: 1831361989
Provider Name (Legal Business Name): KAVARA SUSAN VAUGHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 CHESTNUT RIDGE RD
MORGANTOWN WV
26505-2807
US

IV. Provider business mailing address

930 CHESTNUT RIDGE RD
MORGANTOWN WV
26505-2807
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-5323
  • Fax: 304-293-8724
Mailing address:
  • Phone: 304-293-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number24256
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24256
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: