Provider Demographics
NPI:1083704282
Name:DOCHERTY, GLORIA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:JEAN
Last Name:DOCHERTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6504 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2623
Mailing Address - Country:US
Mailing Address - Phone:708-687-2522
Mailing Address - Fax:
Practice Address - Street 1:15410 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4333
Practice Address - Country:US
Practice Address - Phone:708-633-0060
Practice Address - Fax:708-633-0077
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0920080001OtherMEDICARE DME
IL0040018663OtherBCBS
IL0040018663OtherBCBS
ILL89530Medicare PIN