Provider Demographics
NPI:1720011695
Name:DOHERTY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:2500 NORTH STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS138892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL180300Medicaid
MS00119624Medicaid
MS300085749OtherRAILROAD MEDICARE
MS512G700003OtherMS MEDICARE - GROUP
DC7781OtherRAILROAD MEDICARE GROUP #
MSP01194855OtherRAILROAD MEDICARE PTAN
P00601123OtherRAILROAD MEDICARE
DC7781OtherRAILROAD MEDICARE GROUP #
AL180300Medicaid
MS302I305635Medicare PIN
MS300085749OtherRAILROAD MEDICARE