Provider Demographics
NPI:1871828947
Name:DOUGHERTY, EVAN AUGUSTINE (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:AUGUSTINE
Last Name:DOUGHERTY
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 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-056811207X00000X
IL036137517207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400237018Medicare PIN