Basic Information
| Provider Information | |||||||||
| NPI: | 1184662389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 FISH HATCHERY RD | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082528245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 FISH HATCHERY RD | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082528245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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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 | 207R00000X | 15310-020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31009200 | 05 | WI | MEDICAID | 130 | 01 | WI | DEAN HEALTH INSURANCE | OTHER |