1215045851 NPI number — DANIEL JAMES DOHERTY PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215045851 NPI number — DANIEL JAMES DOHERTY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOHERTY
Provider First Name:
DANIEL
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1215045851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 MACMILLAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04011-3222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-729-8581
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 MALLETT DR
Provider Second Line Business Practice Location Address:
COASTAL ORTHOPEDICS AND SPORTS MEDICINE
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04032-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-442-0325
Provider Business Practice Location Address Fax Number:
207-443-4578
Provider Enumeration Date:
08/25/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT2397 . This is a "LICENSE #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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