Provider Demographics
NPI:1801190665
Name:DOUGHMAN, MATTHEW DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:DOUGHMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-6942
Mailing Address - Fax:740-356-7851
Practice Address - Street 1:1711 27TH ST STE 102
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2657
Practice Address - Country:US
Practice Address - Phone:740-356-1709
Practice Address - Fax:740-353-3027
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003770RX363AM0700X
KYPA1706363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTC091OtherKENTUCKY MEDICAL BOARD
KY7100219770Medicaid
KYPA1706OtherKENTUCKY MEDICAL BOARD
OH0086440Medicaid
1103317OtherNCCPA