Individual
MITCHELL DAUGHERTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1815 E IRELAND RD, SOUTH BEND, IN 46614-2845
(574) 647-1700
(574) 647-7572
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
01082368A
IN
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
01082368A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300003172
—
IN
Enumeration date
04/14/2017
Last updated
06/20/2025
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