Provider Demographics
NPI:1376581603
Name:DOUGHERTY, CATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:
Practice Address - Street 1:3680 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8005
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME762202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2071628OtherAETNA HMO
FLME76220OtherFLORIDA LICENSE
5286666OtherAETNA PPO
FL255037700Medicaid
44339OtherBCBS
2071628OtherAETNA HMO
44339OtherBCBS
FL44339ZMedicare PIN