Provider Demographics
NPI:1578620282
Name:DOHERTY, PATRICK F (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:F
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 1:194 HOWARD ST
Mailing Address - Street 2:SUITE 3 WEST
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-442-0564
Mailing Address - Fax:
Practice Address - Street 1:194 HOWARD ST STE 3
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5544
Practice Address - Country:US
Practice Address - Phone:860-442-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037460207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001374602Medicaid
CT140000206Medicare ID - Type Unspecified
G88122Medicare UPIN