Basic Information
| Provider Information | |||||||||
| NPI: | 1841236593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148425239 | ||||||||
| FaxNumber: | 3148423835 | ||||||||
| Practice Location | |||||||||
| Address1: | 13303 TESSON FERRY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631284062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148425239 | ||||||||
| FaxNumber: | 3148423835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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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 | 208000000X | A88589 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 219515 | 01 | BCBS | OTHER | 219515 | 01 | HEALTHLINK | OTHER | 2700164 | 01 | UHC | OTHER | 6305736 | 01 | CIGNA | OTHER | 319419 | 01 | GHP | OTHER | 72299V34311 | 01 | MO | HEALTHCARE USA | OTHER | 7373873 | 01 | AETNA | OTHER |