Provider Demographics
NPI:1275571978
Name:DAUGHERTY, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:DAUGHERTY
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 1:2925 FOUR PINES DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2971
Mailing Address - Country:US
Mailing Address - Phone:859-266-1862
Mailing Address - Fax:
Practice Address - Street 1:2925 FOUR PINES DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2971
Practice Address - Country:US
Practice Address - Phone:859-266-1862
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14441208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0543002Medicare ID - Type Unspecified
KYD92411Medicare UPIN