Provider Demographics
NPI:1104828722
Name:DAUGHERTY, DARYL FOSTER (MD)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:FOSTER
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8424 NAAB RD
Mailing Address - Street 2:#3-J
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1975
Mailing Address - Country:US
Mailing Address - Phone:317-872-7396
Mailing Address - Fax:317-879-8328
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:#3-J
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1975
Practice Address - Country:US
Practice Address - Phone:317-872-7396
Practice Address - Fax:317-879-8328
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039851A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN524730EMedicare PIN
B47958Medicare UPIN