Provider Demographics
NPI:1598241416
Name:DOHERTY, TARYN LEE (OD)
Entity type:Individual
Prefix:MISS
First Name:TARYN
Middle Name:LEE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9030
Mailing Address - Country:US
Mailing Address - Phone:847-356-2020
Mailing Address - Fax:
Practice Address - Street 1:2120 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9030
Practice Address - Country:US
Practice Address - Phone:847-356-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011206152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046011206OtherLICENSE