Provider Demographics
NPI:1114160439
Name:DOUGHERTY, MICHAEL CHRISTOPHER (IDMT/NREMT-PARAMEDIC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:IDMT/NREMT-PARAMEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 37
Mailing Address - Street 2:BOX 4813
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09459-9998
Mailing Address - Country:US
Mailing Address - Phone:210-858-6699
Mailing Address - Fax:
Practice Address - Street 1:PSC 37
Practice Address - Street 2:BOX 4813
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09459-9998
Practice Address - Country:US
Practice Address - Phone:210-858-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P0923280146L00000X
1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic