Provider Demographics
NPI:1336709096
Name:DOUGHERTY, KELLY ALICE DRIVDAHL (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ALICE DRIVDAHL
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 MOUNT VERNON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3320
Mailing Address - Country:US
Mailing Address - Phone:484-350-2351
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5189
Practice Address - Country:US
Practice Address - Phone:215-707-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT218870207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine