Provider Demographics
NPI:1386326395
Name:DOUGHERTY, ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TILLER RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 W FRONT ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-4702
Practice Address - Country:US
Practice Address - Phone:570-752-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist