Provider Demographics
NPI:1124012000
Name:DOUGHERTY, CHRISTOPHER P (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:P
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3988
Mailing Address - Country:US
Mailing Address - Phone:479-273-1111
Mailing Address - Fax:479-273-1255
Practice Address - Street 1:1504 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3988
Practice Address - Country:US
Practice Address - Phone:479-273-1111
Practice Address - Fax:479-273-1255
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2009-10-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-24
Provider Licenses
StateLicense IDTaxonomies
ARE476114207XX0005X
MO2003014160207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161277002Medicaid
MO206074312Medicaid
AR161277002Medicaid
MO206074312Medicaid