Provider Demographics
NPI:1003822875
Name:WORTHINGTON, MARK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-1612
Practice Address - Country:US
Practice Address - Phone:434-243-3090
Practice Address - Fax:434-244-9445
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054161207R00000X, 207RG0100X
MDD40278207RG0100X
AZ43526207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE56823Medicare UPIN