Healthcare Provider Details

I. General information

NPI: 1639382328
Provider Name (Legal Business Name): PAUL JOSEPH DOUGHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST SUITE 6A
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST SUITE 6A
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4230
  • Fax:
Mailing address:
  • Phone: 313-745-4230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301083727
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number4301083727
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: