Provider Demographics
NPI:1407089261
Name:DOUGHERTY, SEAN MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:MICHAEL
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 PENNSYLVANIA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3509
Mailing Address - Country:US
Mailing Address - Phone:707-426-5644
Mailing Address - Fax:707-426-3156
Practice Address - Street 1:1620 PENNSYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3509
Practice Address - Country:US
Practice Address - Phone:707-426-5644
Practice Address - Fax:707-426-3156
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5009213E00000X, 213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01083197OtherMEDICARE RAILROAD
CAGH339YMedicare PIN
CAP01083197OtherMEDICARE RAILROAD
CAGH339XMedicare PIN