Provider Demographics
NPI:1447356357
Name:DOHERTY, LISA JILL (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JILL
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N. BEST AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-1205
Mailing Address - Country:US
Mailing Address - Phone:610-760-8080
Mailing Address - Fax:610-760-8148
Practice Address - Street 1:330 N BEST AVE
Practice Address - Street 2:
Practice Address - City:WALNUTPORT
Practice Address - State:PA
Practice Address - Zip Code:18088-1205
Practice Address - Country:US
Practice Address - Phone:610-760-8080
Practice Address - Fax:610-760-8148
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008045L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015096280008Medicaid
PA014746Medicare PIN