Provider Demographics
NPI:1912954173
Name:DOCHERTY, STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:DOCHERTY
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:FILE 57430
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:800-819-2424
Mailing Address - Fax:
Practice Address - Street 1:438 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1216
Practice Address - Country:US
Practice Address - Phone:626-289-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5085207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A5085OtherBLUE CROSS
CA00AX50850Medicaid
020A50850OtherBLUE SHIELD
E83897Medicare UPIN
P00126058Medicare PIN
020A50850OtherBLUE SHIELD
CA00AX50850Medicaid