1942268123 NPI number — DAUGHERTY AND DAUGHERTY MEDICAL CLINIC PA

Table of content: (NPI 1942268123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942268123 NPI number — DAUGHERTY AND DAUGHERTY MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAUGHERTY AND DAUGHERTY MEDICAL CLINIC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1942268123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1409 WEST BRADEN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-982-0576
Provider Business Mailing Address Fax Number:
501-982-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 BRADEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72076-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-982-0576
Provider Business Practice Location Address Fax Number:
501-982-0041
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAUGHERTY
Authorized Official First Name:
JOE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-982-0576

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04D0466369 . This is a "CLIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 104806002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS4952 . This is a "RR MCR CLINIC #" identifier . This identifiers is of the category "OTHER".




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