Provider Demographics
NPI:1427163609
Name:DOHERTY, CAROLYN MAUD (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN MAUD
Middle Name:
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 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:717 N 190TH PLZ
Practice Address - Street 2:SUITE # 2500
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-3913
Practice Address - Country:US
Practice Address - Phone:402-815-1915
Practice Address - Fax:402-815-1065
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18934207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA90871Medicaid
IA1427163609Medicaid
NE10024995600Medicaid
IA1427163609Medicaid
E18773Medicare UPIN