Provider Demographics
NPI:1386843852
Name:DOUGHAN, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:DOUGHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ABDUL
Other - Middle Name:
Other - Last Name:DOUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3333 JODECO RD STE A
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5371
Mailing Address - Country:US
Mailing Address - Phone:770-692-4000
Mailing Address - Fax:770-474-8510
Practice Address - Street 1:3333 JODECO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5319
Practice Address - Country:US
Practice Address - Phone:770-692-4000
Practice Address - Fax:770-474-8510
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-15
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056818207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA771350663AMedicaid