Provider Demographics
NPI:1245510932
Name:DAUGHERTY, MATTHEW DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3112
Mailing Address - Country:US
Mailing Address - Phone:936-559-1700
Mailing Address - Fax:
Practice Address - Street 1:3316 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2632
Practice Address - Country:US
Practice Address - Phone:936-559-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDT-519213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist