Provider Demographics
NPI:1306853957
Name:WORTHAM, BRETT MARK (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:MARK
Last Name:WORTHAM
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 26446
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-0446
Mailing Address - Country:US
Mailing Address - Phone:240-472-9926
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME970962080N0001X
DCMD0352952080N0001X
GA0583082080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAPENDINGMedicaid
GAPENDINGMedicare ID - Type UnspecifiedPENDING