Provider Demographics
NPI:1225031594
Name:WORDEN, DONZA THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:DONZA
Middle Name:THOMAS
Last Name:WORDEN
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 506
Mailing Address - Street 2:
Mailing Address - City:PICKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49774
Mailing Address - Country:US
Mailing Address - Phone:906-647-2217
Mailing Address - Fax:906-647-2228
Practice Address - Street 1:33896 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:DRUMMOND ISLAND
Practice Address - State:MI
Practice Address - Zip Code:49726
Practice Address - Country:US
Practice Address - Phone:906-647-2217
Practice Address - Fax:906-647-2228
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3428660Medicaid
D67372Medicare UPIN
MID67372Medicare UPIN
MI3428660Medicaid