Provider Demographics
NPI:1962406538
Name:DOUGHERTY, DOUGLAS ANDREW (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ANDREW
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 FRANKLIN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2910
Mailing Address - Country:US
Mailing Address - Phone:516-248-8334
Mailing Address - Fax:516-248-1357
Practice Address - Street 1:1000 FRANKLIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2910
Practice Address - Country:US
Practice Address - Phone:516-248-8334
Practice Address - Fax:516-248-1357
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01488059Medicaid
NY01488059Medicaid