Provider Demographics
NPI:1124100896
Name:DAUGHERTY, MILTON (MD)
Entity type:Individual
Prefix:
First Name:MILTON
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2016
Mailing Address - Country:US
Mailing Address - Phone:773-947-7900
Mailing Address - Fax:773-947-7901
Practice Address - Street 1:7531 SO STONY ISLAND
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649
Practice Address - Country:US
Practice Address - Phone:773-947-7900
Practice Address - Fax:773-947-7901
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO36-0484342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021609983OtherBLUE CROSS BS
ILO36048434OtherLICENSE
ILO36048434Medicaid
ILIL7698Medicare PIN
IL0021609983OtherBLUE CROSS BS