Provider Demographics
NPI:1225014863
Name:DOHERTY, MAUREEN ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:ANN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817737
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-1737
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4318207L00000X
FLOS7349207L00000X
CO39526207L00000X
MDH0061407207L00000X
MO2004031366207L00000X
TXL8326207L00000X
MI5101016261207L00000X
ARE-4152207L00000X
NC33590207L00000X
GA032551207L00000X
LADO. 000004207L00000X
INDO. 000004207L00000X
WV2153207L00000X
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1477133Medicaid
CO39702243Medicaid
AZ977639Medicaid
CO448648Medicare ID - Type Unspecified
IN222630BMedicare ID - Type Unspecified
LA1477133Medicaid
MDG02148S12Medicare ID - Type UnspecifiedSOUTHERN MD
MD858MJ524Medicare ID - Type Unspecified
AZ106879Medicare ID - Type Unspecified
AZ977639Medicaid
CO39702243Medicaid
FLE33708Medicare UPIN
FL57443Medicare ID - Type Unspecified