Provider Demographics
NPI:1225188840
Name:DOUGHERTY, MATTHEW JOSEPH
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRUCE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-0423
Mailing Address - Country:US
Mailing Address - Phone:215-829-5000
Mailing Address - Fax:
Practice Address - Street 1:700 SPRUCE ST
Practice Address - Street 2:STE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-0423
Practice Address - Country:US
Practice Address - Phone:215-829-5000
Practice Address - Fax:215-627-0578
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD646443L2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013019490001Medicaid
PA0013019490001Medicaid
E54795Medicare UPIN