MEDICARE: DR. DOUGLAS ANDREW DOUGHERTY DO

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	208000000X	Pediatrics Physician	192176	NY

Other Identifiers

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

General Provider Information

NPI Number	:	1962406538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS ANDREW DOUGHERTY DO

Provider Business Mailing Address
First Line	:	1000 FRANKLIN AVE STE 100
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-2910
Country	:	US
Telephone Number	:	516-248-8334
Fax Number	:	516-248-1357

Provider Business Practice Location Address
First Line	:	1000 FRANKLIN AVE STE 100
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-2910
Country	:	US
Telephone Number	:	516-248-8334
Fax Number	:	516-248-1357

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	03/26/2021

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