Provider Demographics
NPI:1720021553
Name:DOUGHERTY, GLEN N JR (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:N
Last Name:DOUGHERTY
Suffix:JR
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:PO BOX 935722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5722
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:2001 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1018
Practice Address - Country:US
Practice Address - Phone:803-254-3278
Practice Address - Fax:803-929-3256
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28734207RC0000X
SCTL28734207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC287344Medicaid
SC287344Medicaid