MEDICARE: JAMES J DOUGHERTY MD

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
1	2083A0100X	Aerospace Medicine Physician	E4302	TX

General Provider Information

NPI Number	:	1295760544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES J DOUGHERTY MD

Provider Business Mailing Address
First Line	:	2454 ISLAND VW
Second Line	:
City	:	CANYON LAKE
State	:	TX
Zip	:	78133-5144
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2454 ISLAND VW
Second Line	:
City	:	CANYON LAKE
State	:	TX
Zip	:	78133-5144
Country	:	US
Telephone Number	:	830-899-7064
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/23/2012

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