Provider Demographics
NPI:1942268123
Name:DAUGHERTY AND DAUGHERTY MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:DAUGHERTY AND DAUGHERTY MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-982-0576
Mailing Address - Street 1:1409 WEST BRADEN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076
Mailing Address - Country:US
Mailing Address - Phone:501-982-0576
Mailing Address - Fax:501-982-0041
Practice Address - Street 1:1409 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3720
Practice Address - Country:US
Practice Address - Phone:501-982-0576
Practice Address - Fax:501-982-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04D0466369OtherCLIA
AR104806002Medicaid
CS4952OtherRR MCR CLINIC #
AR04D0466369OtherCLIA
ARD04485Medicare UPIN
AR=========72076A001OtherHUMANA CLINIC #
ARC68131Medicare UPIN