Provider Demographics
NPI:1710954938
Name:DOUGHERTY, JAMES F (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:F
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4117
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0617
Mailing Address - Country:US
Mailing Address - Phone:815-397-6723
Mailing Address - Fax:815-397-5926
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:STE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:815-397-6723
Practice Address - Fax:815-397-5926
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C37000Medicare UPIN
IL208730Medicare ID - Type Unspecified