Provider Demographics
NPI:1114188711
Name:DOUGHERTY, KEVIN RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RUSSELL
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 WESTERN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4380
Mailing Address - Country:US
Mailing Address - Phone:860-522-0604
Mailing Address - Fax:860-522-1761
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 719
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-522-0604
Practice Address - Fax:860-522-1761
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247283207RC0000X
CT52940207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00585OtherMEDICARE PTAN
CTC00585OtherMEDICARE PTAN