Provider Demographics
NPI:1427120708
Name:DOUGHERTY, KOLLEEN CANNON (MD)
Entity type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:CANNON
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KOLLEEN
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15174207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME306710099Medicaid
MEG84169OtherHPHC
NH30201365Medicaid
MEM166513OtherCIGNA
ME3240685OtherAETNA
ME037553OtherANTHEM
MEG84169Medicare UPIN
MEMM7885Medicare ID - Type Unspecified
ME050069608Medicare ID - Type UnspecifiedRAILROAD