Provider Demographics
NPI:1326049628
Name:DOUGHERTY, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 602
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1475
Mailing Address - Country:US
Mailing Address - Phone:859-277-4005
Mailing Address - Fax:859-278-2507
Practice Address - Street 1:1720 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 602
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1475
Practice Address - Country:US
Practice Address - Phone:859-277-4005
Practice Address - Fax:859-278-2507
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-03-04
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Provider Licenses
StateLicense IDTaxonomies
KY25733207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY110034324OtherRR MEDICARE
KY64257330Medicaid
KY110034324OtherRR MEDICARE
KY64257330Medicaid