Provider Demographics
NPI:1518069236
Name:DOHERTY, KEVIN GLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GLEN
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 TAGGART RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8893
Mailing Address - Country:US
Mailing Address - Phone:740-548-6180
Mailing Address - Fax:740-548-1882
Practice Address - Street 1:6511 TAGGART RD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8893
Practice Address - Country:US
Practice Address - Phone:740-548-6180
Practice Address - Fax:740-548-1882
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005332207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000319608OtherBCBS GREENFIELD
OH0861367Medicaid
OH000000591796OtherBCBS FAYETTE
OH000000591796OtherBCBS FAYETTE
OHDO4011293Medicare PIN
OH0861367Medicaid