Provider Demographics
NPI:1326577859
Name:DOUGHERTY, JACOB RANDALL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RANDALL
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:730 GOODLETTE RD N
Mailing Address - Street 2:STE 102
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5617
Mailing Address - Country:US
Mailing Address - Phone:239-430-3668
Mailing Address - Fax:239-692-9436
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:216-421-3038
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4179213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program