Provider Demographics
NPI:1609260835
Name:DOUGHERTY, RENEE MARIA (DO)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:MARIA
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:1000 ALLIANCE DR
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-3234
Practice Address - Country:US
Practice Address - Phone:484-672-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS023358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty