Healthcare Provider Details

I. General information

NPI: 1841236593
Provider Name (Legal Business Name): MATTHEW DOUGHERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13303 TESSON FERRY RD
SAINT LOUIS MO
63128-4062
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5239
  • Fax: 314-842-3835
Mailing address:
  • Phone: 314-842-5239
  • Fax: 314-842-3835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: