Provider Demographics
NPI:1134228265
Name:DOUGHERTY, MICHAEL JAMES (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWWOD DRIVE
Practice Address - Street 2:SUITE A200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3585
Practice Address - Country:US
Practice Address - Phone:864-454-5125
Practice Address - Fax:864-241-9201
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4041208000000X
SC32324208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC323242Medicaid
SCAA53987951Medicare PIN