Provider Demographics
NPI:1679544365
Name:DAUGHERTY, RHETT L (MD)
Entity Type:Individual
Prefix:DR
First Name:RHETT
Middle Name:L
Last Name:DAUGHERTY
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 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:866-953-3111
Mailing Address - Fax:443-471-8540
Practice Address - Street 1:7704 MATAPEAKE BUSINESS DR STE 310
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3046
Practice Address - Country:US
Practice Address - Phone:866-953-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06345000208800000X
MDD0091343208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05654157OtherAETNA
0863531000OtherAMERIHEALTH
G21334Medicare UPIN
05654157OtherAETNA