Provider Demographics
NPI:1598137820
Name:M J DOHERTY PLLC
Entity Type:Organization
Organization Name:M J DOHERTY PLLC
Other - Org Name:DOHERTY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-961-0843
Mailing Address - Street 1:1151 ELLIS ST # 202
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5203
Mailing Address - Country:US
Mailing Address - Phone:360-746-2380
Mailing Address - Fax:
Practice Address - Street 1:1151 ELLIS ST # 202
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5203
Practice Address - Country:US
Practice Address - Phone:360-746-2380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020973207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty