Basic Information
Provider Information | |||||||||
NPI: | 1326577859 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGHERTY | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | RANDALL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 730 GOODLETTE RD N | ||||||||
Address2: | STE 102 | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341025617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2394303668 | ||||||||
FaxNumber: | 2396929436 | ||||||||
Practice Location | |||||||||
Address1: | 10701 EAST BLVD | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167913800 | ||||||||
FaxNumber: | 2164213038 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO4179 | FL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.