Provider Demographics
NPI:1306834122
Name:DAUGHERTY, JOHN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6876
Mailing Address - Country:US
Mailing Address - Phone:865-494-9241
Mailing Address - Fax:865-494-2522
Practice Address - Street 1:110 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6876
Practice Address - Country:US
Practice Address - Phone:865-494-9241
Practice Address - Fax:865-494-2522
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000021373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN125762OtherBLUE CROSS
TN080030188OtherRAILROAD MEDICARE
TN3062410Medicaid
TN125762OtherBLUE CROSS
TN3062410Medicaid