Basic Information
| Provider Information | |||||||||
| NPI: | 1598044463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARILYN DOUGHERTY MD., PC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803053344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034493770 | ||||||||
| FaxNumber: | 3034495383 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803053344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034493770 | ||||||||
| FaxNumber: | 3034495383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 09/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | DOUGHERTY | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3034493770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 23203 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 01232032 | 05 | CO | MEDICAID |