Individual
CHRISTOPHER R DOUGHERTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AA
Contact information
Practice address
11141 PARKVIEW PLAZA DR STE 200, FORT WAYNE, IN 46845-1714
(260) 425-6030
(260) 425-6028
Mailing address
PO BOX 2580, SPRINGFIELD, MO 65801-2580
(417) 829-4620
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
2012029911
MO
367H00000X
Anesthesiologist Assistant
Primary
75000180A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1720336548
—
MO
01
—
431560263
TRICARE
MO
01
—
P01129104
RR MCR
MO
Enumeration date
08/28/2012
Last updated
07/15/2024
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