Provider Demographics
NPI:1245590264
Name:DOUGHERTY, MICHAEL KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
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 1:2417 ATRIUM DR STE 150
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6673
Mailing Address - Country:US
Mailing Address - Phone:919-791-2040
Mailing Address - Fax:919-791-2041
Practice Address - Street 1:2417 ATRIUM DR STE 150
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6673
Practice Address - Country:US
Practice Address - Phone:919-791-2040
Practice Address - Fax:919-791-2041
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT201715207R00000X
NC2016-00550207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine