Healthcare Provider Details

I. General information

NPI: 1609260835
Provider Name (Legal Business Name): RENEE MARIA DOUGHERTY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ALLIANCE DR
HAZLETON PA
18202-3234
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 484-672-8810
  • Fax:
Mailing address:
  • Phone: 484-884-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS023358
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: