Provider Demographics
NPI:1043875974
Name:DOHERTY, TREVOR JAMES
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:JAMES
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 STILLSON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3212
Mailing Address - Country:US
Mailing Address - Phone:203-209-2106
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY # 2FW-095
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-5218
Practice Address - Fax:212-932-5258
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant