Provider Demographics
NPI:1952403651
Name:DOUGHERTY, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:DOUGHERTY
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 1:1019 SKINKER PKWY
Mailing Address - Street 2:156
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-2355
Mailing Address - Country:US
Mailing Address - Phone:678-793-7963
Mailing Address - Fax:
Practice Address - Street 1:1019 SKINKER PKWY
Practice Address - Street 2:156
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-2355
Practice Address - Country:US
Practice Address - Phone:678-793-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29906207QS0010X, 207P00000X, 207Q00000X
MO2009024720207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB69237Medicare UPIN