1629078084 NPI number — DR. MANUEL PRESTON DAUGHERTY MD

Table of content: DR. MANUEL PRESTON DAUGHERTY MD (NPI 1629078084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629078084 NPI number — DR. MANUEL PRESTON DAUGHERTY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
MANUEL
Provider Middle Name:
PRESTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629078084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40480
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36640-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-665-8200
Provider Business Mailing Address Fax Number:
251-665-8210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 CENTER ST
Provider Second Line Business Practice Location Address:
STE 3N
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36604-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-665-8200
Provider Business Practice Location Address Fax Number:
251-665-8210
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  3645 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200046072 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000053083 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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