Provider Demographics
NPI:1427025311
Name:DAUGHERTY, ROBERT MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:DAUGHERTY
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 1:454 WEST ST
Mailing Address - Street 2:
Mailing Address - City:FROHNA
Mailing Address - State:MO
Mailing Address - Zip Code:63748-9143
Mailing Address - Country:US
Mailing Address - Phone:573-979-1809
Mailing Address - Fax:888-523-2655
Practice Address - Street 1:1854 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4553
Practice Address - Country:US
Practice Address - Phone:573-271-2923
Practice Address - Fax:888-523-2655
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4199213E00000X
IL016005170213ES0103X
AR250213ES0103X
MO2004013247213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005170Medicaid
MO2474055OtherUNITEDHEALTHCARE
MO307288514Medicaid
MO5621628OtherFIRST HEALTH
MO197250OtherBLUE CROSS BLUE SHEILD
MO706133OtherHEALTHLINK
MO307288506Medicaid
MO307288514Medicaid
MO706133OtherHEALTHLINK
ILP00137033Medicare PIN
MO257905528Medicare PIN
MO197250OtherBLUE CROSS BLUE SHEILD