Provider Demographics
NPI:1881632289
Name:DOUGHERTY, LAURA WAIKART (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:WAIKART
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LEE
Other - Last Name:WAIKART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2137
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2137
Mailing Address - Country:US
Mailing Address - Phone:828-575-2644
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:103 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3456
Practice Address - Country:US
Practice Address - Phone:803-794-3581
Practice Address - Fax:803-791-7286
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28749207K00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA16666874OtherMEDICARE PTAN
SCTL28749OtherSC MEDICAL LICENSE #