Basic Information
| Provider Information | |||||||||
| NPI: | 1003862350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803353 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | MOB SUITE 308 | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803353 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G61638 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Y00000X | G61638 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.