Provider Demographics
NPI:1326054404
Name:DOUGHERTY, WILLIAM E (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:E
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 1:927 BROADWAY ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-6423
Mailing Address - Fax:217-222-9807
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-224-6423
Practice Address - Fax:217-222-9807
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114502208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114502Medicaid
IL110073OtherHEALTH ALLIANCE
ILK23251Medicare ID - Type UnspecifiedWPS
IL036114502Medicaid