Provider Demographics
NPI:1699712232
Name:DOUGHERTY, THOMAS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:DOUGHERTY
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 1:15627 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1627
Mailing Address - Country:US
Mailing Address - Phone:714-990-0911
Mailing Address - Fax:714-256-9172
Practice Address - Street 1:15627 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1627
Practice Address - Country:US
Practice Address - Phone:714-990-0911
Practice Address - Fax:714-256-9172
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27977207RC0000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G279770OtherBLUE SHIELD ID #
023927OtherHEALTH NET ID #
CA00G279770Medicaid
110060919OtherRAILROAD
CAWG27977TMedicare PIN
023927OtherHEALTH NET ID #
CAWG27977RMedicare PIN
00G279770OtherBLUE SHIELD ID #
CAWG27977TMedicare PIN