Provider Demographics
NPI:1255435558
Name:DOHERTY, TERRENCE A (MD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:A
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 1:447 MONTAUK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-447-1426
Mailing Address - Fax:860-447-0348
Practice Address - Street 1:19 HALLS RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1457
Practice Address - Country:US
Practice Address - Phone:860-434-8300
Practice Address - Fax:860-865-2388
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT029476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1294769Medicaid
CT1294769Medicaid
CT080001077Medicare PIN