Provider Demographics
NPI:1265666515
Name:WORTMAN, CHARLES GRADY (IDMT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GRADY
Last Name:WORTMAN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MDG
Mailing Address - Street 2:UNIT 3865
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09126-3865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 MDG
Practice Address - Street 2:UNIT 3865
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126-3865
Practice Address - Country:US
Practice Address - Phone:0657-590-2919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians