Provider Demographics
NPI:1487654299
Name:DOUGHERTY, BRIAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:8940 N KENDALL DR
Practice Address - Street 2:#504E
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2148
Practice Address - Country:US
Practice Address - Phone:305-595-6200
Practice Address - Fax:786-533-1680
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41833207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043195800Medicaid
FL34013XMedicare ID - Type Unspecified
FL043195800Medicaid