Provider Demographics
NPI:1407073653
Name:DOUGHERTY, MIRIAM THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:THERESA
Last Name:DOUGHERTY
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 1:2000 WASHINGTON ST STE 206
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1602
Mailing Address - Country:US
Mailing Address - Phone:617-332-6311
Mailing Address - Fax:617-243-5650
Practice Address - Street 1:2000 WASHINGTON ST STE 206
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1602
Practice Address - Country:US
Practice Address - Phone:617-332-6311
Practice Address - Fax:617-243-5650
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA46091207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6173624Medicaid
MDMA46091OtherMEDICAL LICENSE
MDMA46091OtherMEDICAL LICENSE