Provider Demographics
NPI:1467423871
Name:DOHERTY, MARK GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GERARD
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 N GEORGE MASON DR
Mailing Address - Street 2:SUITE 475
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3683
Mailing Address - Country:US
Mailing Address - Phone:703-717-4000
Mailing Address - Fax:703-717-4009
Practice Address - Street 1:1625 N GEORGE MASON DR
Practice Address - Street 2:SUITE 475
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3683
Practice Address - Country:US
Practice Address - Phone:703-717-4000
Practice Address - Fax:703-717-4009
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48014207VX0201X, 207VG0400X
TXH4087207VG0400X, 207VX0201X
WAMD60066893207VG0400X
WAMD 60066893207VX0201X
VA0101257128207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136867209Medicaid
WAG8884737OtherMEDICARE - SNO CO
TN48014OtherTENNESSEE LICENSE
TX8R1427OtherBCBS
TX136867505Medicaid
VA1467423871Medicaid
OK100000460AMedicaid
TX136867213Medicaid
TXH4087OtherMEDICAL LICENSURE
TX136867216Medicaid
TN48014OtherTENNESSEE LICENSE
OK100000460AMedicaid
TX88268KMedicare PIN
TX980000035Medicare PIN
VA1467423871Medicaid
WAG8879741Medicare PIN
TX8A6046Medicare PIN