Healthcare Provider Details

I. General information

NPI: 1801892260
Provider Name (Legal Business Name): MARK J. DOHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 ELLIS ST STE 202
BELLINGHAM WA
98225-5245
US

IV. Provider business mailing address

1793 13TH ST SE
SALEM OR
97302-2541
US

V. Phone/Fax

Practice location:
  • Phone: 360-746-2380
  • Fax: 360-746-2382
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00020973
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD00020973
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: