Provider Demographics
NPI:1710055041
Name:WORTZ, GARY NATHANAEL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:NATHANAEL
Last Name:WORTZ
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 1:2353 ALEXANDRIA DR STE 260
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3208
Mailing Address - Country:US
Mailing Address - Phone:859-224-2655
Mailing Address - Fax:859-223-7147
Practice Address - Street 1:2353 ALEXANDRIA DR STE 260
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3208
Practice Address - Country:US
Practice Address - Phone:859-224-2655
Practice Address - Fax:859-223-7147
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40650207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000571982OtherANTHEM
KY9293157OtherAETNA
KY7100063600Medicaid
KY40650OtherKY MEDICAL LICENSE
KY0744160OtherCIGNA
FLME104362OtherMEDICAL LICENSE
FLME104362OtherMEDICAL LICENSE
KY40650OtherKY MEDICAL LICENSE
KY006760001Medicare PIN
KY00676Medicare PIN