Provider Demographics
NPI:1811958895
Name:DOUGHERTY, KATHLEEN C (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
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 1:802 NEW HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2163
Mailing Address - Country:US
Mailing Address - Phone:717-560-3782
Mailing Address - Fax:717-560-3787
Practice Address - Street 1:802 NEW HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2163
Practice Address - Country:US
Practice Address - Phone:717-560-3782
Practice Address - Fax:717-560-3787
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041845L2084P0800X, 2084F0202X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA233185OtherVALUE OPTIONS
PA50056697OtherCAPITAL BLUE CROSS
PA12204570004Medicaid
PA621495OtherHIGHMARK BLUE SHIELD
PA0012204570001Medicaid
PA0012204570005Medicaid
PA233185OtherVALUE OPTIONS
PAA15797Medicare UPIN
PA50056697OtherCAPITAL BLUE CROSS