Basic Information
| Provider Information | |||||||||
| NPI: | 1144544164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260001 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD STE 206 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257671156 | ||||||||
| FaxNumber: | 2257675980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2010 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 205766 | LA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 54562 | TN | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 54562 | TN | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 205766 | LA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 216071001 | 05 | AR | MEDICAID | 08603276 | 05 | MS | MEDICAID | 6082717 | 01 | TN | BCBS | OTHER | Q023627 | 05 | TN | MEDICAID |