1417925009 NPI number — DENNIS VICTOR WORTHINGTON MD

Table of content: DENNIS VICTOR WORTHINGTON MD (NPI 1417925009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417925009 NPI number — DENNIS VICTOR WORTHINGTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WORTHINGTON
Provider First Name:
DENNIS
Provider Middle Name:
VICTOR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417925009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2539 MEDICAL DR STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88310-8720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-446-5940
Provider Business Mailing Address Fax Number:
575-446-5944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2539 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-8720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-446-5940
Provider Business Practice Location Address Fax Number:
575-446-5944
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  95380 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: G43294 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H4189 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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