Provider Demographics
NPI:1902899149
Name:DOTY, DAVID KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KENNETH
Last Name:DOTY
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 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1100
Mailing Address - Fax:952-942-3361
Practice Address - Street 1:4706 WOODLAND DR E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2303
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:952-942-3361
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0490062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3323297OtherMEDICARE 855R
KY91716OtherSIHO-KCR
KY64129620Medicaid
GA00875641AMedicaid
KY3427936000OtherPASSPORT ADVANTAGE
VA010348293Medicaid
PA102112303Medicaid
KY50017681OtherPASSPORT-KCR
KY000000548193OtherANTHEM-KCR
PA102112303Medicaid
KY593617Medicare PIN
OHDO7381591Medicare PIN
GAH16316Medicare UPIN
PA123334-FLTMedicare PIN
KY0998894Medicare PIN
KY00011007Medicare PIN
KY50017681OtherPASSPORT-KCR
KY3427936000OtherPASSPORT ADVANTAGE
VA12539P27Medicare PIN