Provider Demographics
NPI:1518938935
Name:WORTHINGTON, RICHARD DENISON (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DENISON
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 1:2307 STAUP RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:MI
Mailing Address - Zip Code:49248-9723
Mailing Address - Country:US
Mailing Address - Phone:517-436-3714
Mailing Address - Fax:
Practice Address - Street 1:950 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2603
Practice Address - Country:US
Practice Address - Phone:419-354-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.061974207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0912249Medicaid
P00221047Medicare PIN
OHF51794Medicare UPIN
OH0912249Medicaid