Provider Demographics
NPI:1295727519
Name:DOUGHERTY, KURT W (OD)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:W
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5500
Mailing Address - Country:US
Mailing Address - Phone:260-422-6396
Mailing Address - Fax:260-420-2258
Practice Address - Street 1:3401 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5500
Practice Address - Country:US
Practice Address - Phone:260-422-6396
Practice Address - Fax:260-420-2258
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1800214R152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100103980AMedicaid
IN0155420001Medicare NSC
T69207Medicare UPIN
IN100103980AMedicaid