Healthcare Provider Details

I. General information

NPI: 1699712232
Provider Name (Legal Business Name): THOMAS MICHAEL DOUGHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15627 IMPERIAL HWY
LA MIRADA CA
90638-1627
US

IV. Provider business mailing address

15627 IMPERIAL HWY
LA MIRADA CA
90638-1627
US

V. Phone/Fax

Practice location:
  • Phone: 714-990-0911
  • Fax: 714-256-9172
Mailing address:
  • Phone: 714-990-0911
  • Fax: 714-256-9172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG27977
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG27977
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: