Provider Demographics
NPI:1912965187
Name:DAUGHERTY, JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 BRADEN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-3720
Mailing Address - Country:US
Mailing Address - Phone:501-982-0576
Mailing Address - Fax:501-982-0041
Practice Address - Street 1:1409 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3720
Practice Address - Country:US
Practice Address - Phone:501-982-0576
Practice Address - Fax:501-982-0041
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5414114OtherAETNA
AR080042776OtherRR MEDICARE
AR114330000OtherQUALCHOICE
AR105932001Medicaid
ARP01065091OtherRRMCARE
ARSCHUMACHER GR TSG IDOther1547
ARD04485Medicare UPIN
AR51286Medicare PIN
ARSCHUMACHER GR TSG IDOther1547