Basic Information
| Provider Information | |||||||||
| NPI: | 1700079837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T., A.T.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 45TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199228188 | ||||||||
| FaxNumber: | 2199228502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 45TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199228188 | ||||||||
| FaxNumber: | 2199228502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 05001844A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2255A2300X | 36000225A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.