Provider Demographics
NPI:1043200553
Name:DOHERTY, SHAWN PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PAUL
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-3311
Mailing Address - Country:US
Mailing Address - Phone:601-445-4282
Mailing Address - Fax:601-445-9197
Practice Address - Street 1:611 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-3311
Practice Address - Country:US
Practice Address - Phone:601-445-4282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1466727Medicaid
410047920OtherRR MEDICARE
MS00880060Medicaid
T21025Medicare UPIN
MS00880060Medicaid
MS4485620001Medicare NSC