Provider Demographics
NPI:1013977446
Name:DOUGHERTY, BERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:G
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7455 W WASHINGTON AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4340
Mailing Address - Country:US
Mailing Address - Phone:702-732-3441
Mailing Address - Fax:702-732-2310
Practice Address - Street 1:3059 S MARYLAND PKWY
Practice Address - Street 2:100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2294
Practice Address - Country:US
Practice Address - Phone:702-732-3441
Practice Address - Fax:702-732-2310
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV13408207ZP0102X
AZ41713207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ41743Medicare PIN
LAB90132Medicare UPIN