Provider Demographics
NPI:1205274347
Name:WORTHINGTON, BART D (DO)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:D
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 SANTA PATRICIA CT
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6138
Mailing Address - Country:US
Mailing Address - Phone:907-385-0257
Mailing Address - Fax:
Practice Address - Street 1:2957 SANTA PATRICIA CT
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-6138
Practice Address - Country:US
Practice Address - Phone:907-385-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.063615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1712390Medicaid