Healthcare Provider Details

I. General information

NPI: 1942238027
Provider Name (Legal Business Name): JOHN J DOUGHERTY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 CARONDELET DR STE 220
KANSAS CITY MO
64114-4822
US

IV. Provider business mailing address

1010 CARONDELET DR STE 220
KANSAS CITY MO
64114-4822
US

V. Phone/Fax

Practice location:
  • Phone: 816-941-1600
  • Fax: 816-941-1699
Mailing address:
  • Phone: 816-941-1600
  • Fax: 816-941-1699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number104398
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: