Provider Demographics
NPI:1992744965
Name:DOHERTY, THOMAS W (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:DOHERTY
Suffix:
Gender:M
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 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3080 HAMILTON BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3694
Practice Address - Country:US
Practice Address - Phone:484-661-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072864L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50053635OtherCAPITAL BLUE CROSS
PA1436570OtherKEYSTONE HEALTH PLAN
PA2120932000OtherKEYSTONE EAST
PA64414Medicare ID - Type Unspecified
PAH16286Medicare UPIN
PA1436570OtherHIGHMARK BLUE SHIELD