Provider Demographics
NPI:1437413812
Name:DOHERTY, AMY LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYNN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:DOHERTY SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9240
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.062322207Q00000X
IL036.137970207Q00000X
WI65068-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine