Provider Demographics
NPI:1134796477
Name:DOUGHERTY, BRADY
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 NW 18TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-9074
Mailing Address - Country:US
Mailing Address - Phone:515-957-4042
Mailing Address - Fax:
Practice Address - Street 1:1360 NW 18TH ST STE 101
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9074
Practice Address - Country:US
Practice Address - Phone:515-957-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA109563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor