Provider Demographics
NPI:1568407070
Name:WORNOM, ISAAC LEAKE III
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:LEAKE
Last Name:WORNOM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14401 SOMMERVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6836
Mailing Address - Country:US
Mailing Address - Phone:804-285-4115
Mailing Address - Fax:804-673-6714
Practice Address - Street 1:1630 WILKES RIDGE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7460
Practice Address - Country:US
Practice Address - Phone:804-285-4115
Practice Address - Fax:804-673-6714
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010439242086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009999558Medicaid
VA001455R18Medicare ID - Type Unspecified
VAE61722Medicare UPIN