Provider Demographics
NPI:1871526012
Name:DAUGHTRY, BARRY T (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:T
Last Name:DAUGHTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3410
Practice Address - Fax:920-433-3469
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56171-20207Q00000X
IL036092570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00979727Medicare Oscar/Certification
G91399Medicare UPIN
WI002150271Medicare Oscar/Certification
WI072900070Medicare Oscar/Certification