Provider Demographics
NPI:1518953165
Name:DAUGHERTY, PHILIP V II (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:V
Last Name:DAUGHERTY
Suffix:II
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 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-308-0280
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:455 N HIGHLAND PARK AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-209-6070
Practice Address - Fax:423-209-6071
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN17556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029107Medicaid
TN30439581Medicaid
GA000588277FMedicaid