Provider Demographics
NPI:1669443644
Name:DOUGHERTY, JANET MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:MARIE
Last Name:DOUGHERTY
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 1:9409 B OLD BURKE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015
Mailing Address - Country:US
Mailing Address - Phone:703-978-4200
Mailing Address - Fax:703-503-8263
Practice Address - Street 1:3501 LOISDALE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-359-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5617685Medicaid
VA007969B05Medicare PIN
F40846Medicare UPIN
VA5617685Medicaid