Provider Demographics
NPI:1699073619
Name:DAUGHERTY, FOREST DALE (MD)
Entity type:Individual
Prefix:DR
First Name:FOREST
Middle Name:DALE
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 1:4041 SHOSHONEE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2531
Mailing Address - Country:US
Mailing Address - Phone:812-372-5688
Mailing Address - Fax:
Practice Address - Street 1:4041 SHOSHONEE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2531
Practice Address - Country:US
Practice Address - Phone:812-372-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010118019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine