Healthcare Provider Details

I. General information

NPI: 1134114770
Provider Name (Legal Business Name): GERALD W DOHERTY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 KERWIN HILL RD
NORWICH VT
05055-9475
US

IV. Provider business mailing address

79 KERWIN HILL RD
NORWICH VT
05055-9475
US

V. Phone/Fax

Practice location:
  • Phone: 802-649-3225
  • Fax: 802-371-4488
Mailing address:
  • Phone: 802-649-3225
  • Fax: 802-371-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0030712
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: