Provider Demographics
NPI: | 1629017355 |
---|---|
Name: | DOHERTY, MELISSA J (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MELISSA |
Middle Name: | J |
Last Name: | DOHERTY |
Suffix: | |
Gender: | F |
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: | PO BOX 4078 |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97208-4078 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-633-0086 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1255 HILYARD ST |
Practice Address - Street 2: | |
Practice Address - City: | EUGENE |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97401-3718 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-686-7300 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-06 |
Last Update Date: | 2007-12-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | MD24499 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 227514 | Medicaid | |
8939235 | Other | WASHINGTON CRIME VICTIMS | |
H73744 | Other | LIPA | |
CA | XPY199702 | Medicaid | |
CA | XPY199702 | Medicaid | |
R117177 | Medicare PIN | ||
8939235 | Other | WASHINGTON CRIME VICTIMS | |
CD2802 | Medicare PIN | ||
0000WFBBX | Medicare PIN |