Provider Demographics
NPI:1922625920
Name:WORTHEM, DARRELL WAYNE SR (LSA)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:WAYNE
Last Name:WORTHEM
Suffix:SR
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-3335
Mailing Address - Country:US
Mailing Address - Phone:817-901-0943
Mailing Address - Fax:
Practice Address - Street 1:801 W SEVENTH ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3510
Practice Address - Country:US
Practice Address - Phone:682-885-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00816246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant