Provider Demographics
NPI:1619991890
Name:DOUGHERTY EVANS, DANA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:LYNN
Last Name:DOUGHERTY EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:LYNN
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:STE.300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-894-2444
Practice Address - Fax:502-894-2445
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082494207Q00000X
KY46382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2422453Medicaid
OHDO4117721Medicare ID - Type Unspecified