1871562017 NPI number — DR. NEIL E DOHERTY III MD

Table of content: DR. NEIL E DOHERTY III MD (NPI 1871562017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871562017 NPI number — DR. NEIL E DOHERTY III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOHERTY
Provider First Name:
NEIL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871562017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
235 E BADILLO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91723-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-915-4700
Provider Business Mailing Address Fax Number:
626-857-7340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
552 W FOOTHILL BLVD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91741-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-915-4700
Provider Business Practice Location Address Fax Number:
626-214-7815
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G51688 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G516880 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WG51688A . This is a "MEDICARE PPIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: G51688 . This is a "MEDICAL BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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