Provider Demographics
NPI:1801892260
Name:DOHERTY, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:1151 ELLIS ST STE 202
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5245
Practice Address - Country:US
Practice Address - Phone:360-746-2380
Practice Address - Fax:360-746-2382
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00020973207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8180382Medicaid
WA0230370OtherL&I/CRIME VICTIMS
WA8180382Medicaid
WAB 65451Medicare UPIN