Healthcare Provider Details

I. General information

NPI: 1962849885
Provider Name (Legal Business Name): MICHAEL ROBERT DAUGHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2013
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 5037
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 5037
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4975
  • Fax: 513-636-6753
Mailing address:
  • Phone: 513-636-4975
  • Fax: 513-636-6753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number35.133607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: