Provider Demographics
NPI:1235205253
Name:WORTHEN, WILLARD FRANK II (MD)
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:FRANK
Last Name:WORTHEN
Suffix:II
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 1:555 E HARDY ST
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4011
Mailing Address - Country:US
Mailing Address - Phone:310-680-8391
Mailing Address - Fax:310-412-4501
Practice Address - Street 1:555 E HARDY ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4011
Practice Address - Country:US
Practice Address - Phone:310-680-8391
Practice Address - Fax:310-412-4501
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27872207ZP0102X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91092Medicare UPIN
CAWG27872DMedicare ID - Type Unspecified333 N PRAIRIE PRACTICE
CAWG27872EMedicare ID - Type Unspecified4650 LINCOLN PRACTICE