Provider Demographics
NPI:1912268038
Name:DAUGHERTY, ALISSA K (MD)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:K
Last Name:DAUGHERTY
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4044 FORT CAMPBELL BLVD
Mailing Address - Street 2:PMB# 124
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-4950
Mailing Address - Country:US
Mailing Address - Phone:502-322-5219
Mailing Address - Fax:999-999-9999
Practice Address - Street 1:4044 FORT CAMPBELL BLVD
Practice Address - Street 2:PMB# 124
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4950
Practice Address - Country:US
Practice Address - Phone:270-839-2298
Practice Address - Fax:999-999-9999
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2018-12-19
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Provider Licenses
StateLicense IDTaxonomies
KY47177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100253410Medicaid
KY7100253410Medicaid
KY7100253410Medicaid
KYP01253566OtherRAILROAD MEDICARE
KYK083932Medicare PIN