Provider Demographics
NPI:1508072711
Name:DOUGHERTY, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
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 1:2020 PALOMINO LANE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:2020 PALOMINO LANE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1518
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRTN98962085R0202X
NV161992085R0202X
NVSP3772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC153000500OtherDOL
NC219592OtherMEDCOST
NC760158OtherMAMSI
NC145U7OtherBCBS OF NC
NC153000500OtherDOL
NCNCD098E798Medicare PIN
NCNCD098AMedicare PIN
NCP00432841Medicare PIN