Provider Demographics
NPI:1154376697
Name:DOHERTY, MARYELLEN
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 ASH ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:687 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-1518
Practice Address - Country:US
Practice Address - Phone:508-222-3200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA120183207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP29614Medicare UPIN
MANP3182Medicare ID - Type Unspecified