Provider Demographics
NPI:1891069035
Name:MARIA DIGNA DOHERTY, M.D., PA
Entity Type:Organization
Organization Name:MARIA DIGNA DOHERTY, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDO
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:352-420-8118
Mailing Address - Street 1:11525 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-7373
Mailing Address - Country:US
Mailing Address - Phone:352-596-9990
Mailing Address - Fax:352-596-9997
Practice Address - Street 1:11525 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-7373
Practice Address - Country:US
Practice Address - Phone:352-596-9990
Practice Address - Fax:352-596-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062700170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371279600Medicaid