Provider Demographics
NPI:1114091329
Name:WORNER, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:WORNER
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 1:2106 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76164-8511
Mailing Address - Country:US
Mailing Address - Phone:817-625-4254
Mailing Address - Fax:817-625-8451
Practice Address - Street 1:2106 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-8511
Practice Address - Country:US
Practice Address - Phone:817-625-4254
Practice Address - Fax:817-625-8451
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113550103Medicaid
TX8160J4Medicare ID - Type Unspecified
TX113550103Medicaid