Provider Demographics
NPI:1376781682
Name:DONALD D DOTY
Entity Type:Organization
Organization Name:DONALD D DOTY
Other - Org Name:DOTY FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOANLD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-337-3661
Mailing Address - Street 1:PO BOX 773
Mailing Address - Street 2:
Mailing Address - City:BLUE JAY
Mailing Address - State:CA
Mailing Address - Zip Code:92317-0773
Mailing Address - Country:US
Mailing Address - Phone:909-337-3661
Mailing Address - Fax:909-337-3570
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:STE 112
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-337-3661
Practice Address - Fax:909-337-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG06093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC36166Medicare UPIN
CAOOOG60930Medicare PIN