Provider Demographics
NPI:1003890740
Name:DOUGHERTY, THOMAS H (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:H
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE B510
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-8850
Mailing Address - Fax:304-523-9470
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUITE B510
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-8850
Practice Address - Fax:304-523-9470
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22471207ZP0102X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2694866Medicaid
WV3810006887Medicaid
4194331Medicare PIN
I62541Medicare UPIN