Provider Demographics
NPI:1932335312
Name:DOGHERRA, DEANA JOY (IDMT)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:JOY
Last Name:DOGHERRA
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD BLDG 2825
Mailing Address - Street 2:
Mailing Address - City:EGLIN
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1391
Mailing Address - Country:US
Mailing Address - Phone:850-883-8207
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD BLDG 2825
Practice Address - Street 2:
Practice Address - City:EGLIN
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians