Basic Information
| Provider Information | |||||||||
| NPI: | 1417481540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | MITCHELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 W JEFFERSON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471670 | ||||||||
| FaxNumber: | 5746476927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2017 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 01082368A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 01082368A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 236040377 | 01 | IN | MEDICARE PTAN | OTHER | 261970152 | 01 | IN | MEDICARE PTAN | OTHER | 300003172 | 05 | IN | MEDICAID |