Provider Demographics
NPI:1023094950
Name:DAUGHERTY, WILSON PARRISH (MD, PH D)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:PARRISH
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD, PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 RIVERVIEW AVE STE 202A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1065
Mailing Address - Country:US
Mailing Address - Phone:757-252-9140
Mailing Address - Fax:757-793-4149
Practice Address - Street 1:301 RIVERVIEW AVE STE 202A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1065
Practice Address - Country:US
Practice Address - Phone:757-252-9140
Practice Address - Fax:757-793-4149
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259100207T00000X
NC2011-01173207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC1629AMedicare PIN
I41886Medicare UPIN