Provider Demographics
NPI:1497842512
Name:DOUGHERTY, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
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 1:1331 MAESTAS RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6268
Mailing Address - Country:US
Mailing Address - Phone:575-776-7806
Mailing Address - Fax:575-224-7806
Practice Address - Street 1:1331 MAESTAS RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6268
Practice Address - Country:US
Practice Address - Phone:575-776-7806
Practice Address - Fax:575-224-7806
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD389862086S0127X
PAMD071147L2086S0127X
NMMD2010-07932086S0127X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD932970OtherCAREFIRST MD BCBS
F30625Medicare UPIN