Provider Demographics
NPI:1679580492
Name:WORTHAM, REX EMERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:EMERSON
Last Name:WORTHAM
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 1:8 S 1ST W
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1244
Mailing Address - Country:US
Mailing Address - Phone:208-852-0852
Mailing Address - Fax:208-852-0568
Practice Address - Street 1:8 S 1ST W
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1244
Practice Address - Country:US
Practice Address - Phone:208-852-0852
Practice Address - Fax:208-852-0568
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA73177Medicare UPIN
ID1137220Medicare ID - Type Unspecified