Provider Demographics
NPI:1265534895
Name:DOUGHERTY, EUGENE (PA)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 ZENA RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-2626
Mailing Address - Country:US
Mailing Address - Phone:845-679-5271
Mailing Address - Fax:845-679-0726
Practice Address - Street 1:404 ZENA RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2626
Practice Address - Country:US
Practice Address - Phone:845-679-5271
Practice Address - Fax:845-679-0726
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0019071363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P63100Medicare UPIN
5F315Medicare ID - Type Unspecified