Provider Demographics
NPI:1447387170
Name:VAUGHN, WANDA (OD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2549
Mailing Address - Country:US
Mailing Address - Phone:479-478-8860
Mailing Address - Fax:479-478-8890
Practice Address - Street 1:1021 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2549
Practice Address - Country:US
Practice Address - Phone:479-478-8860
Practice Address - Fax:479-478-8890
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2554152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200055390AMedicaid
AR156558722Medicaid
AR5411590001Medicare NSC
AR156558722Medicaid