Provider Demographics
NPI:1023217437
Name:WORMACK, CASSANDRA (MD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39465 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2205 JOLLY RD
Practice Address - Street 2:STE. B
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3983
Practice Address - Country:US
Practice Address - Phone:517-347-4085
Practice Address - Fax:517-347-4170
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072467207V00000X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5199852Medicaid
MII03983Medicare UPIN