Basic Information
| Provider Information | |||||||||
| NPI: | 1184716938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | REZA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 LEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349249400 | ||||||||
| FaxNumber: | 4349821618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | C10007905 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 207PP0204X | C10007905 | DE | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 2085R0202X | C10007905 | DE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD419063 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 0101264628 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0001830 | 05 | NJ | MEDICAID | 1184716938 | 05 | VA | MEDICAID | 4100646 | 05 | MD | MEDICAID |