Healthcare Provider Details

I. General information

NPI: 1730154261
Provider Name (Legal Business Name): MICHAEL G DOHERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SANDSTONE CIR
JACKSON TN
38305-2073
US

IV. Provider business mailing address

31 SANDSTONE CIR
JACKSON TN
38305-2073
US

V. Phone/Fax

Practice location:
  • Phone: 731-240-1747
  • Fax: 731-240-1755
Mailing address:
  • Phone: 731-240-1747
  • Fax: 731-240-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301087295
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number68642
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: