Provider Demographics
NPI:1942521208
Name:JOHN J. DOHERTY, M.D., PH.D., INC.
Entity Type:Organization
Organization Name:JOHN J. DOHERTY, M.D., PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:310-540-5566
Mailing Address - Street 1:21350 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 258
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5605
Mailing Address - Country:US
Mailing Address - Phone:310-540-5566
Mailing Address - Fax:310-540-8577
Practice Address - Street 1:21350 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 258
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5605
Practice Address - Country:US
Practice Address - Phone:310-540-5566
Practice Address - Fax:310-540-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5897216Medicaid
CAA22978Medicare UPIN