Provider Demographics
NPI:1164641130
Name:DOUGHERTY, JACQUELYN M (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N UNION RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5339
Mailing Address - Country:US
Mailing Address - Phone:716-634-4441
Mailing Address - Fax:716-634-3174
Practice Address - Street 1:40 N UNION RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5339
Practice Address - Country:US
Practice Address - Phone:716-634-4441
Practice Address - Fax:716-634-3174
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist