Provider Demographics
NPI:1215909064
Name:DOUGHERTY, MARY ELIZABETH (OD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:DUEWER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:18780 COX AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070
Mailing Address - Country:US
Mailing Address - Phone:408-370-7303
Mailing Address - Fax:408-370-7405
Practice Address - Street 1:18780 COX AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070
Practice Address - Country:US
Practice Address - Phone:408-370-7303
Practice Address - Fax:408-370-7405
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10582T152W00000X
MN2531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U59123Medicare UPIN
CASD0105820Medicare ID - Type Unspecified