Provider Demographics
NPI:1245735133
Name:DOUGHERTY, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:3401 NORTH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3743
Mailing Address - Country:US
Mailing Address - Phone:225-381-6620
Mailing Address - Fax:
Practice Address - Street 1:2404 N COURTENAY PKWY STE D
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4127
Practice Address - Country:US
Practice Address - Phone:321-453-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148451207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine