Provider Demographics
NPI:1760426878
Name:DAUGHERTY, RICHARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 104780
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4780
Mailing Address - Country:US
Mailing Address - Phone:573-632-0243
Mailing Address - Fax:573-632-6900
Practice Address - Street 1:3400 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5712
Practice Address - Country:US
Practice Address - Phone:573-632-2777
Practice Address - Fax:573-632-2769
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD115048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203825906Medicaid
MO0002012984Medicare NSC
MO203825906Medicaid