Healthcare Provider Details

I. General information

NPI: 1245256502
Provider Name (Legal Business Name): THOMAS DOUGHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 MAIN ST
CLARENCE NY
14031-2043
US

IV. Provider business mailing address

9900 MAIN ST
CLARENCE NY
14031-2043
US

V. Phone/Fax

Practice location:
  • Phone: 716-759-8811
  • Fax: 716-759-2042
Mailing address:
  • Phone: 716-759-8811
  • Fax: 716-759-2042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number146390
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: