Healthcare Provider Details

I. General information

NPI: 1184885881
Provider Name (Legal Business Name): AMY DOUGHERTY D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY E MCCANDLESS D.P.M.

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 ROOSEVELT BLVD SUITE 203
PHILADELPHIA PA
19152-3038
US

IV. Provider business mailing address

8001 ROOSEVELT BLVD SUITE 203
PHILADELPHIA PA
19152-3038
US

V. Phone/Fax

Practice location:
  • Phone: 215-332-5300
  • Fax: 215-332-5228
Mailing address:
  • Phone: 215-332-5300
  • Fax: 215-332-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00320000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberSC006066
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006066
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00320000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: