Provider Demographics
NPI:1053561761
Name:ROBERT JAMES DOUGHERTY MDPA
Entity type:Organization
Organization Name:ROBERT JAMES DOUGHERTY MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-581-5016
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-0023
Mailing Address - Country:US
Mailing Address - Phone:512-581-5016
Mailing Address - Fax:
Practice Address - Street 1:441 HIGHWAY 71 W
Practice Address - Street 2:SUITE B-1
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3931
Practice Address - Country:US
Practice Address - Phone:512-581-5016
Practice Address - Fax:512-581-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147638403Medicaid
00754FMedicare PIN
H44653Medicare UPIN