Provider Demographics
NPI:1245256502
Name:DOUGHERTY, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-2043
Mailing Address - Country:US
Mailing Address - Phone:716-759-8811
Mailing Address - Fax:716-759-2042
Practice Address - Street 1:9900 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-2043
Practice Address - Country:US
Practice Address - Phone:716-759-8811
Practice Address - Fax:716-759-2042
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005002791OtherPROVIDER ID BLUE CROSS
NY0101390OtherPROVIDER ID INDEPENDENT H
NY0010047701OtherPROVIDER ID UNIVERA
NY0101390OtherPROVIDER ID INDEPENDENT H
NY0010047701OtherPROVIDER ID UNIVERA