Provider Demographics
NPI:1184885881
Name:DOUGHERTY, AMY (DPM)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:MCCANDLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:8001 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3038
Mailing Address - Country:US
Mailing Address - Phone:215-332-5300
Mailing Address - Fax:215-332-5228
Practice Address - Street 1:8001 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3038
Practice Address - Country:US
Practice Address - Phone:215-332-5300
Practice Address - Fax:215-332-5228
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00320000213EP1101X, 213ES0103X
PASC006066213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7844107Medicaid
PA1030852380001Medicaid
NJ7844107Medicaid
PA425970MNAMedicare PIN