Individual
CHARLES DOUGHERTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
13303 TESSON FERRY RD, SAINT LOUIS, MO 63128-4062
(314) 842-5239
(314) 842-3835
Mailing address
PO BOX 23340, SAINT LOUIS, MO 63156-3340
(314) 842-5239
(314) 842-3835
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
R6070
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100732
HEALTHLINK
MO
01
—
1200163
UHC
MO
01
—
17699
BCB
MO
01
—
40000261
AETNA
MO
01
—
40420
GHP
MO
01
—
5724V34311
HEALTHCARE USA
MO
Enumeration date
11/08/2005
Last updated
09/21/2012
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