Provider Demographics
NPI:1205856374
Name:DOHERTY, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:21350 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 258
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5605
Mailing Address - Country:US
Mailing Address - Phone:310-540-5566
Mailing Address - Fax:310-540-8577
Practice Address - Street 1:21350 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 258
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5605
Practice Address - Country:US
Practice Address - Phone:310-540-5566
Practice Address - Fax:310-540-8577
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA22240173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22978Medicare UPIN