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General NPI Number Information
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NPI Number | 1932186210
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Entity Type | Individual
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Provider Name | MICHAEL D DOUGHERTY P.A.
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Gender | Male
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Dates
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Enumeration Date | 12/28/2005
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 611 SHERMAN AVE EAST
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City | FORT ATKINSON
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State | WI
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Zip | 53538
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Country | US
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Telephone | 920-568-5330
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Fax |
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Provider Business Mailing Address
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Address Line | 6400 INDUSTRIAL LOOP
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City | GREENDALE
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State | WI
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Zip | 53129-2452
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Country | US
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Telephone | 414-423-4100
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Fax | 414-423-4134
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 848-023
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License Number State | WI
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