Provider Demographics
NPI:1336180249
Name:DOHERTY, KEVIN PATRICK (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PATRICK
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:13537 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5866
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:14825 N OUTER FORTY ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-0002
Practice Address - Country:US
Practice Address - Phone:636-812-1211
Practice Address - Fax:636-812-0159
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20060094472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151100022Medicare PIN
MO150900023Medicare PIN