Provider Demographics
NPI:1730154261
Name:DOHERTY, MICHAEL G (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
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 1:31 SANDSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2073
Mailing Address - Country:US
Mailing Address - Phone:731-240-1747
Mailing Address - Fax:731-240-1755
Practice Address - Street 1:31 SANDSTONE CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2073
Practice Address - Country:US
Practice Address - Phone:731-240-1747
Practice Address - Fax:731-240-1755
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010872952085R0204X, 2085R0202X
TN686422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN604658400Medicaid
H24767Medicare UPIN
MN604658400Medicaid
MN020047203Medicare ID - Type UnspecifiedRAILROAD