MEDICARE: DR. MARK GERARD DOHERTY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VX0201X	Gynecologic Oncology Physician	48014	TN
2	207VG0400X	Gynecology Physician	48014	TN
3	207VG0400X	Gynecology Physician	H4087	TX
4	207VX0201X	Gynecologic Oncology Physician	H4087	TX
5	207VG0400X	Gynecology Physician	MD60066893	WA
6	207VX0201X	Gynecologic Oncology Physician	MD 60066893	WA
7	207VX0201X	Gynecologic Oncology Physician	0101257128	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	G8884737	OTHER	WA	MEDICARE - SNO CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	48014	OTHER	TN	TENNESSEE LICENSE
4	8R1427	OTHER	TX	BCBS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	H4087	OTHER	TX	MEDICAL LICENSURE
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467423871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK GERARD DOHERTY MD

Provider Business Mailing Address
First Line	:	1625 N GEORGE MASON DR
Second Line	:	SUITE 475
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3683
Country	:	US
Telephone Number	:	703-717-4000
Fax Number	:	703-717-4009

Provider Business Practice Location Address
First Line	:	1625 N GEORGE MASON DR
Second Line	:	SUITE 475
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3683
Country	:	US
Telephone Number	:	703-717-4000
Fax Number	:	703-717-4009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	04/16/2015

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Directions to “ DR. MARK GERARD DOHERTY MD” Practice Location

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