1336317429 NPI number — MR. JOSEPH THOMAS DOHERTY RPH

Table of content: MR. JOSEPH THOMAS DOHERTY RPH (NPI 1336317429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336317429 NPI number — MR. JOSEPH THOMAS DOHERTY RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOHERTY
Provider First Name:
JOSEPH
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1336317429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 WOODLAND TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRICK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11566-3114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-867-0685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 CORPORATE DR
Provider Second Line Business Practice Location Address:
T1139
Provider Business Practice Location Address City Name:
WESTBURY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11590-6614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-222-8841
Provider Business Practice Location Address Fax Number:
516-222-8841
Provider Enumeration Date:
02/12/2008

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: 183500000X , with the licence number:  029842 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01892608 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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