Provider Demographics
NPI:1588100184
Name:DOHERTY, DANIEL LEO JR (PA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:LEO
Last Name:DOHERTY
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:259 E ERIE ST FL 17
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-926-6000
Mailing Address - Fax:312-926-0516
Practice Address - Street 1:259 E ERIE ST FL 17
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-926-6000
Practice Address - Fax:312-926-0516
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2021-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085008221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant