Provider Demographics
NPI:1467460246
Name:WORTHINGTON, DOUGLAS K (AUD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7499
Mailing Address - Fax:801-373-5980
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 401
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7499
Practice Address - Fax:801-373-5980
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8233519-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00333022Medicare ID - Type UnspecifiedRAILROAD
MN640000320Medicare ID - Type Unspecified