=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881705085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JAMES DOUGHTIE ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 COLLEGE AVE TUFTS UNIVERSITY - SOUSENS GYM
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-627-5145
-----------------------------------------------------
Fax | 617-627-2185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 MAPLEWOOD RD
-----------------------------------------------------
City | STOUGHTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-344-1724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 10
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------