Provider Demographics
NPI:1093978512
Name:DOHERTY, COLLEEN PATRICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:PATRICIA
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E CHICAGO AVE
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2637
Mailing Address - Country:US
Mailing Address - Phone:312-944-6677
Mailing Address - Fax:312-944-3346
Practice Address - Street 1:211 E CHICAGO AVE
Practice Address - Street 2:SUITE 1050
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2637
Practice Address - Country:US
Practice Address - Phone:312-944-6677
Practice Address - Fax:312-944-3346
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054401207R00000X
IL036127488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine