Provider Demographics
NPI:1013919034
Name:VAN WORMER, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:VAN WORMER
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 1:314 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-3302
Mailing Address - Country:US
Mailing Address - Phone:575-374-8313
Mailing Address - Fax:575-374-2064
Practice Address - Street 1:314 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3302
Practice Address - Country:US
Practice Address - Phone:575-374-8313
Practice Address - Fax:575-374-2064
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81333208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
060000475OtherRAILROAD MEDICARE
NM05645Medicaid
NM05645Medicaid
060000475OtherRAILROAD MEDICARE
NM2130903Medicare PIN