Provider Demographics
NPI:1649255332
Name:DOUGHERTY, SARA ELLEN (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ELLEN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7420 GREENHAVEN DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831
Mailing Address - Country:US
Mailing Address - Phone:916-399-6015
Mailing Address - Fax:916-394-3344
Practice Address - Street 1:7420 GREENHAVEN DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831
Practice Address - Country:US
Practice Address - Phone:916-399-6015
Practice Address - Fax:916-394-3344
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A69860Medicaid
CAH87196Medicare UPIN
CA00A69860Medicaid