Provider Demographics
NPI:1669854725
Name:DAUGHERTY MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:DAUGHERTY MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:859-371-2600
Mailing Address - Street 1:9200 MONTGOMERY RD SUITE 18A
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:859-371-2600
Mailing Address - Fax:859-372-5923
Practice Address - Street 1:9200 MONTGOMERY RD SUITE 18A
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242
Practice Address - Country:US
Practice Address - Phone:859-371-2600
Practice Address - Fax:859-372-5923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty