Provider Demographics
NPI:1417925009
Name:WORTHINGTON, DENNIS VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:VICTOR
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 1:2539 MEDICAL DR STE 107
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8720
Mailing Address - Country:US
Mailing Address - Phone:575-446-5940
Mailing Address - Fax:575-446-5944
Practice Address - Street 1:2539 MEDICAL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8720
Practice Address - Country:US
Practice Address - Phone:575-446-5940
Practice Address - Fax:575-446-5944
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95380207RG0100X
CAG43294207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH4189Medicaid
A49302Medicare UPIN