Provider Demographics
NPI:1760650725
Name:DAUGHERTY FOOT & ANKLE CLINIC
Entity Type:Organization
Organization Name:DAUGHERTY FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:573-335-7100
Mailing Address - Street 1:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-2046
Mailing Address - Country:US
Mailing Address - Phone:573-335-7100
Mailing Address - Fax:573-335-7106
Practice Address - Street 1:37 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4956
Practice Address - Country:US
Practice Address - Phone:573-335-7100
Practice Address - Fax:573-335-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004013247213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5717990001Medicare NSC