Healthcare Provider Details

I. General information

NPI: 1164051637
Provider Name (Legal Business Name): MAX LOGAN DOUGHERTY MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 MADISON AVE
NEW YORK NY
10029-6542
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number320619
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: