Provider Demographics
NPI:1851556369
Name:WORTHY, RAY BONNER (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:BONNER
Last Name:WORTHY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4933 WABASH ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001
Mailing Address - Country:US
Mailing Address - Phone:504-780-2766
Mailing Address - Fax:504-780-9699
Practice Address - Street 1:4933 WABASH ST.
Practice Address - Street 2:BIOBEHAVIORAL MEDICINE
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001
Practice Address - Country:US
Practice Address - Phone:504-780-2766
Practice Address - Fax:504-780-9699
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2053582084P0800X, 2084A0401X
SCLL311552084P0800X
LA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4R216CB63Medicare UPIN