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General NPI Number Information
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NPI Number | 1972582534
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Entity Type | Individual
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Provider Name | GRANVILLE LEROY VAUGHAN III M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/12/2006
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Last Update Date | 11/30/2009
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Provider Practice Location Address
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Address Line | 2225 HIGHWAY 110 W
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City | HEBER SPRINGS
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State | AR
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Zip | 72543-3404
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Country | US
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Telephone | 501-326-0048
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Fax | 501-362-8815
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Provider Business Mailing Address
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Address Line | PO BOX 1018 2225 HIGHWAY 110 WEST
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City | HEBER SPRINGS
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State | AR
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Zip | 72543-1018
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Country | US
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Telephone | 501-362-0048
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Fax | 501-362-8815
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C7548
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License Number State | AR
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