Healthcare Provider Details

I. General information

NPI: 1356046122
Provider Name (Legal Business Name): EVAN BLAKE DAUGHERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MULLICA HILL RD
MULLICA HILL NJ
08062-4413
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-508-8000
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA12890600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: