MEDICARE: DR. SUSAN A VAUGHAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2026	OK
2	152W00000X	Optometrist	2405	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	6928350001	OTHER	OK	CIGNA GOVERNEMENT SERVICES

General Provider Information

NPI Number	:	1124065479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN A VAUGHAN O.D.

Provider Business Mailing Address
First Line	:	820 STATELINE RD
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-1348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 STATELINE RD
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-1348
Country	:	US
Telephone Number	:	918-422-5811
Fax Number	:	918-422-5709

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	10/20/2014

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