Provider Demographics
NPI:1417396664
Name:DOUGHERTY, DIANA L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:L
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 1:3947 COLONIAL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1405
Mailing Address - Country:US
Mailing Address - Phone:245-101-2777
Mailing Address - Fax:
Practice Address - Street 1:WEED ARMY COMMUNITY HOSPITAL, PCMH
Practice Address - Street 2:390 OUTER LOOP
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine