Provider Demographics
NPI:1033292529
Name:WORTHMAN, TRAVIS (DC)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:WORTHMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 DEERCREST DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-7611
Mailing Address - Country:US
Mailing Address - Phone:229-244-9579
Mailing Address - Fax:
Practice Address - Street 1:2418 BEMISS ROAD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-219-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20-287-0408OtherTAX ID
GAV07368Medicare UPIN
GA35ZCJLKMedicare ID - Type Unspecified