Healthcare Provider Details

I. General information

NPI: 1720336548
Provider Name (Legal Business Name): CHRISTOPHER R DOUGHERTY AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11141 PARKVIEW PLAZA DR STE 200
FORT WAYNE IN
46845-1714
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6030
  • Fax: 260-425-6028
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2012029911
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number75000180A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: