Healthcare Provider Details

I. General information

NPI: 1457167066
Provider Name (Legal Business Name): CARSON A DOUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3459 5TH AVE
PITTSBURGH PA
15213-3236
US

IV. Provider business mailing address

2817 WESTBROOK DR APT 315
FORT WAYNE IN
46805-2027
US

V. Phone/Fax

Practice location:
  • Phone: 412-647-7645
  • Fax:
Mailing address:
  • Phone: 317-903-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: