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Individual

DR. KURT W. DOUGHERTY

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
OD

Contact information

Practice address
3401 LAKE AVE, FORT WAYNE, IN 46805-5500
(260) 422-6396
(260) 420-2258
Mailing address
3401 LAKE AVE, FORT WAYNE, IN 46805-5500
(260) 422-6396
(260) 420-2258

Taxonomy

Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1800214R
IN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
100103980A
IN
Enumeration date
08/23/2005
Last updated
06/18/2008
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