Provider Demographics
NPI:1750391777
Name:DOHERTY, DENNIS C (DO)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:C
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7101
Mailing Address - Country:US
Mailing Address - Phone:706-991-9865
Mailing Address - Fax:424-220-7408
Practice Address - Street 1:2 S MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7101
Practice Address - Country:US
Practice Address - Phone:706-991-9865
Practice Address - Fax:424-220-7408
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031731174400000X
GA31731207L00000X, 208VP0000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20270G8239OtherPTAN
GA270301394OtherTAX ID