MEDICARE: DONN M DOUGHERTY M.D.

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	207Q00000X	Family Medicine Physician	DD406638	MI
2	207Q00000X	Family Medicine Physician	28871-020	WI

General Provider Information

NPI Number	:	1992735351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONN M DOUGHERTY M.D.

Provider Business Mailing Address
First Line	:	760 PILGRIM WAY
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5263
Country	:	US
Telephone Number	:	920-496-4700
Fax Number	:

Provider Business Practice Location Address
First Line	:	760 PILGRIM WAY
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5263
Country	:	US
Telephone Number	:	920-496-4700
Fax Number	:

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	02/26/2010

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