Healthcare Provider Details

I. General information

NPI: 1356978449
Provider Name (Legal Business Name): THOMAS MICHAEL DOUGHERTY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 DEL PRADO BLVD S STE 6
CAPE CORAL FL
33990-2661
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-2755
  • Fax: 239-424-2756
Mailing address:
  • Phone: 239-424-2755
  • Fax: 239-424-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number173633
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME173633
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: