Provider Demographics
NPI:1497123384
Name:DOHERTY, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:3261 NW MOUNT VINTAGE WAY STE 221
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-6039
Mailing Address - Country:US
Mailing Address - Phone:360-479-1952
Mailing Address - Fax:360-479-0318
Practice Address - Street 1:3261 NW MOUNT VINTAGE WAY STE 221
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6039
Practice Address - Country:US
Practice Address - Phone:360-479-1952
Practice Address - Fax:360-479-0318
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61107726207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2179758Medicaid