Provider Demographics
NPI:1821030479
Name:DOUGHTY, KYLE EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:EDWARD
Last Name:DOUGHTY
Suffix:
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1158
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-820-8585
Mailing Address - Fax:214-820-8590
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 1158
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-820-8585
Practice Address - Fax:214-820-8590
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1077207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174501004Medicaid
TX147501001Medicaid
TX174501002Medicaid
TX8BR085OtherBCBS
TX8P8217OtherBCBS
TXP00718252Medicare PIN
TX8P8217OtherBCBS
TX174501002Medicaid
TX147501001Medicaid
TX8L2772Medicare PIN
TX8D6454Medicare PIN