Provider Demographics
NPI:1558556621
Name:WORTHINGTON, ETHAN B (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:B
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-928-4412
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:805 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2110
Practice Address - Country:US
Practice Address - Phone:601-928-4412
Practice Address - Fax:601-928-4792
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6041733OtherHEALTHSPRING
MS9912622OtherAETNA
MSP00896972OtherRAILROAD MEDICARE
MS06001526Medicaid