Provider Demographics
NPI:1487046694
Name:DOUGHERTY, TIMOTHY JOSEPH (NP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5785
Mailing Address - Country:US
Mailing Address - Phone:337-312-8247
Mailing Address - Fax:337-493-4355
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-312-8249
Practice Address - Fax:337-312-6711
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2386611Medicaid
LA2386611Medicaid
LAP01660197Medicare PIN