Provider Demographics
NPI:1720336548
Name:DOUGHERTY, CHRISTOPHER R (AA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-6030
Practice Address - Fax:260-425-6028
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012029911367H00000X
IN75000180A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP01129104OtherRR MCR
MO1720336548Medicaid
MOP01129104OtherRR MCR