Healthcare Provider Details

I. General information

NPI: 1801190665
Provider Name (Legal Business Name): MATTHEW DAVID DOUGHMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 27TH ST STE 102
PORTSMOUTH OH
45662-2657
US

IV. Provider business mailing address

1735 27TH ST STE B06
PORTSMOUTH OH
45662-2681
US

V. Phone/Fax

Practice location:
  • Phone: 740-356-1709
  • Fax: 740-353-3027
Mailing address:
  • Phone: 740-356-6942
  • Fax: 740-356-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.003770RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1706
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: