Healthcare Provider Details

I. General information

NPI: 1407089261
Provider Name (Legal Business Name): SEAN MICHAEL DOUGHERTY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 PENNSYLVANIA AVE STE A
FAIRFIELD CA
94533-3509
US

IV. Provider business mailing address

1620 PENNSYLVANIA AVE STE A
FAIRFIELD CA
94533-3509
US

V. Phone/Fax

Practice location:
  • Phone: 707-426-5644
  • Fax: 707-426-3156
Mailing address:
  • Phone: 707-426-5644
  • Fax: 707-426-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5009
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE5009
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE5009
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: