Provider Demographics
NPI:1003862350
Name:DOHERTY, CAROLYN M (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:DOHERTY
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 1:400 N PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-3353
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:MOB SUITE 308
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3353
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61638207Q00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine