Healthcare Provider Details

I. General information

NPI: 1467567073
Provider Name (Legal Business Name): MICHAEL DOUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 QUANTUM LAKES DR SUITE 108
BOYNTON BEACH FL
33426-8324
US

IV. Provider business mailing address

2500 QUANTUM LAKES DR SUITE 108
BOYNTON BEACH FL
33426-8324
US

V. Phone/Fax

Practice location:
  • Phone: 561-244-3627
  • Fax: 561-244-9627
Mailing address:
  • Phone: 561-244-3627
  • Fax: 561-244-9627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: