Provider Demographics
NPI:1134100100
Name:DOUGHERTY, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:DOUGHERTY
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-842-5239
Mailing Address - Fax:314-842-3835
Practice Address - Street 1:13303 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:314-842-5239
Practice Address - Fax:314-842-3835
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO40420OtherGHP
MO17699OtherBCB
MO1200163OtherUHC
MO40000261OtherAETNA
MO100732OtherHEALTHLINK
MO5724V34311OtherHEALTHCARE USA
MO328422451Medicare PIN
MO017011188Medicare PIN
MO17699OtherBCB