Provider Demographics
NPI:1245224864
Name:WORTHINGTON, DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:WORTHINGTON
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 1:201 N MAYFAIR ROAD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-259-7480
Mailing Address - Fax:414-259-7481
Practice Address - Street 1:201 N MAYFAIR ROAD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-259-7480
Practice Address - Fax:414-259-7481
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23370207VM0101X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30340800Medicaid
WI1245224864Medicaid
WI0001Medicare ID - Type Unspecified
WI30340800Medicaid