Provider Demographics
NPI:1386616415
Name:DOUGHERTY, PATRICK (DPM)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 DRESSER CT STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7325
Mailing Address - Country:US
Mailing Address - Phone:919-872-2022
Mailing Address - Fax:919-872-2087
Practice Address - Street 1:1004 DRESSER CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7325
Practice Address - Country:US
Practice Address - Phone:919-872-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC740213ES0103X, 213EP1101X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6712460018OtherMEDICARE NSC RALEIGH
NC6712460024OtherMEDICARE NSC HENDERSON