Provider Demographics
NPI:1164504197
Name:WORTHAM, DONALD GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GENE
Last Name:WORTHAM
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 1:19109 36TH AVE W
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5767
Mailing Address - Country:US
Mailing Address - Phone:425-744-7771
Mailing Address - Fax:425-744-7774
Practice Address - Street 1:19109 36TH AVE W
Practice Address - Street 2:SUITE 109
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5767
Practice Address - Country:US
Practice Address - Phone:425-744-7771
Practice Address - Fax:425-744-7774
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020164261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAREGENCEOtherWO009
WALABOR & INDUSTRYOther107361
WALABOR & INDUSTRYOther107361
WAE72553Medicare UPIN