Provider Demographics
NPI:1922412279
Name:DOUGHERTY, KEVIN S (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3409
Mailing Address - Country:US
Mailing Address - Phone:307-578-2000
Mailing Address - Fax:
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2014-06-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021230207P00000X
WI68949-21207P00000X
WY14756A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine