Provider Demographics
NPI:1043555964
Name:DOUGHTY, DANIEL (CO)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4000
Mailing Address - Country:US
Mailing Address - Phone:631-689-6606
Mailing Address - Fax:631-382-8995
Practice Address - Street 1:9 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4000
Practice Address - Country:US
Practice Address - Phone:631-689-6606
Practice Address - Fax:631-382-8995
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4229970001Medicare PIN