Provider Demographics
NPI:1477725752
Name:DAUGHERTY, JAMES L (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11559 CUMBERLAND RD
Mailing Address - Street 2:#300
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9787
Mailing Address - Country:US
Mailing Address - Phone:317-594-5000
Mailing Address - Fax:317-594-5056
Practice Address - Street 1:11559 CUMBERLAND RD
Practice Address - Street 2:#300
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9787
Practice Address - Country:US
Practice Address - Phone:317-594-5000
Practice Address - Fax:317-594-5056
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001586AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100426950Medicaid
INU40646Medicare UPIN
IN100426950Medicaid