Provider Demographics
NPI:1871791236
Name:DOHERTY, LISA L (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-2385
Practice Address - Fax:360-414-2386
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60132321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500618521Medicaid
WA2006642Medicaid
WA0261154OtherLABOR & INDUSTRIES
WA0261154OtherLABOR & INDUSTRIES