Provider Demographics
NPI:1932108461
Name:WORTMAN, PAUL DOUGLASS (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DOUGLASS
Last Name:WORTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:127 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3755
Mailing Address - Country:US
Mailing Address - Phone:336-893-8423
Mailing Address - Fax:336-893-8426
Practice Address - Street 1:127 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3755
Practice Address - Country:US
Practice Address - Phone:336-893-8423
Practice Address - Fax:336-893-8426
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35791207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0300482OtherUNITED HEALTHCARE
P00371225OtherRAILROAD MEDICARE
NC89261OtherBCBS NC
E2611OtherMEDCOST
4521OtherPARTNERS
6309395OtherCIGNA
NC8989261Medicaid
5975022OtherAETNA
NC89261OtherBCBS NC
5975022OtherAETNA
P00371225Medicare PIN