Provider Demographics
NPI:1033285119
Name:DOHERTY VISION CLINIC PA
Entity Type:Organization
Organization Name:DOHERTY VISION CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-445-4282
Mailing Address - Street 1:611 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-3311
Mailing Address - Country:US
Mailing Address - Phone:601-445-4282
Mailing Address - Fax:601-445-4266
Practice Address - Street 1:611 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-3311
Practice Address - Country:US
Practice Address - Phone:601-445-4282
Practice Address - Fax:601-445-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4485620001Medicare NSC
MSC02714Medicare PIN