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NPI Code Detail

MEDICARE: DR. KURT W. DOUGHERTY OD

MEDICARE: DR. KURT W. DOUGHERTY OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist1800214RIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1295727519
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KURT W. DOUGHERTY OD
Provider Business Mailing Address
First Line : 3401 LAKE AVE
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-5500
Country : US
Telephone Number : 260-422-6396
Fax Number : 260-420-2258
Provider Business Practice Location Address
First Line : 3401 LAKE AVE
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-5500
Country : US
Telephone Number : 260-422-6396
Fax Number : 260-420-2258
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/23/2005
Last Update Date : 06/18/2008

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