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General NPI Number Information
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NPI Number | 1700079837
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Entity Type | Individual
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Provider Name | JOHN JOSEPH DOHERTY P.T., A.T.C.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 08/22/2007
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Provider Practice Location Address
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Address Line | 1950 45TH AVE SUITE 200
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City | MUNSTER
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State | IN
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Zip | 46321-3917
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Country | US
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Telephone | 219-922-8188
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Fax | 219-922-8502
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Provider Business Mailing Address
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Address Line | 1950 45TH AVE SUITE 200
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City | MUNSTER
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State | IN
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Zip | 46321-3917
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Country | US
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Telephone | 219-922-8188
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Fax | 219-922-8502
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 05001844A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36000225A
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License Number State | IN
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