Provider Demographics
NPI:1457746448
Name:DOHERTY, JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1613
Mailing Address - Country:US
Mailing Address - Phone:414-358-5420
Mailing Address - Fax:414-329-1001
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-1000
Practice Address - Fax:262-329-1001
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67554207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457746448Medicaid