Provider Demographics
NPI:1295840833
Name:WORNDLE, JOHAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:WORNDLE
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 1:30 E APPLE ST
Mailing Address - Street 2:SUITE NW 3300
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-2900
Mailing Address - Fax:937-208-8388
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:SUITE NW 3300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-2900
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088285207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2672648Medicaid
OHH014932Medicare PIN
OH4190212Medicare PIN
OHH014931Medicare PIN
OH2672648Medicaid
OH4190211Medicare PIN